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NOTES 


OPERATIVE  DENTISTRY 


MARSHALL  H.  WEBB,  D.D.S., 

Xecturer  on  Operative  Dentistrj-  and  Dental  Histology  in  the  Dental  Department   of  the 
University  of  Pennsylvania  ;  Blember  of  the  American  Dental  Association  ;  Pennsyl- 
vania State  Dental  Society  ;    New  York  Odontological  Society  ;    Odontological " 
Society  of  Pennsylvania  ;   Harris  Dental  Association  of  Lancaster,  Pa.  ; 
and  Honorary  Member  of  the  Dental  Society  of  the  State  of  New 
York,  and  of  several  other  Dental  Associations. 


SECOND   EDITION. 


PHILADELPHIA: 

The  S.  S.  White  Dental  Manufacturing  Company. 
1883. 


copyright. 

The  S.  S.  White  Dental  Mfg.  Co. 
1883. 


PreHs  ot  Patterson  &  White. 


TABLE  OF  CONTENTS. 


FAOE 

Histology 10 

The  Deciduous  TeetJi — Prevention  of  Irregularity  and 

Decay 52 

Application  of  the  Kubber  Dam 60 

Preparation  of  Filling  Materials 67 

The  Mallet 72 

Filling  Cavities  in  Masticating  Surfaces  ...      89 

Filling  Cavities  within  Labial  and  Buccal  Walls  .  .  93 
Pieces  of  Porcelain  for  Filling  Cavities  of  Decay  .  .  96 
Filling  Cavities  within  Aj^proximal  Walls  .  .  .100 
Preparation  of  Cavities  for  Restoration  of  Contour  .  104 
Restoration  of  Contour,  and  Prevention  of  Extension  of 

Decay Ill 

Summary  of  Principles  relating  to  Filling  Teeth    .         .117 

Covering  and  Protecting  Frail  Walls  of  Enamel    with 

Gold 119 

Placing  Crowns  on  Roots  of  Teeth  ....  124 

Attaching  Crowns  to  Teeth  where  Roots  are  Missing    .  134 

Irritation  and  Death  of  the  Pulp     .         .         .         .         .  150 

Filling  Pulp-Chambers 157 

Treatment  of  Abscess 160 

Pericementitis  ........  164 

Necrosis 168 


PREFACE. 


THESE  Notes  on  Operative  Dentistry  are  published 
for  the  purpose  of  aiding  those  engaged  in  per- 
forming operations  for  the  preservation  of  the  natural 
teeth,  and  to  enable  the  earnest,  careful  student,  who 
possesses  the  necessary  ability,  to  become  such  a  practi- 
tioner as  every  one  should  desire  and  aim  to  be, — the 
author  believing  that  if  the  methods  described  are  faith- 
fully followed  each  such  student  can  make  of  himself  a 
really  fine  operator. 

In  the  description  of  details,  the  modes  of  treatment 
of  the  teeth  and  of  operating  upon  them  must  necessa- 
rily be  the  methods  practiced  by  the  author,  and  he  gives 
those  only  which  have  proved  to  be — not  the  easiest  but 
— the  very  best.  The  methods  followed  by  different  prac- 
titioners vary  so  much  that  it  is  almost  impossible  to 
ascertain  and  award  the  credit  due  to  the  author  of  each  ; 
but  the  methods  and  suggestions  of  several  first-class 
operators  will  be  given  with  due  credit  in  those  cases  in 
which  the  special  plan  of  operating  is  distinctive  enough 
to  have  become  associated  with  the  name  pf  the  practi- 
tioner. 

The  results  of  the  recent  investigations  made  in  his- 
tology by  Prof.  Carl  Heitzmann  and  Dr.  C.  F.  W.  Bo- 
decker,  of  New  York,  are  quoted  or  stated  in  the  first 

V 


Vl  PREFACE, 

part  of  this  work,  partly  because  that  which  follows  was 
written  in  the  light  of  these  latest  and  best  discoveries, 
partly  for  the  reason  that  the  nearer  perfect  our  knowl- 
edge of  the  dental  and  other  tissues  and  their  elements, 
and  of  the  living  matter  throughout  and  connecting  them 
all,  the  better  qualified  we  are  to  make  fine  discrimina- 
tions in  reference  to  deviations  from  normal  action,  and 
the  more  fully  prepared  we  become  for  the  prevention 
and  treatment  or  cure  of  disease. 

The  closing  part,  which  is  a  selection  from  the  writings 
of  Dr.  W.  H.  Atkinson,  of  'New  York,  on  "  Eeproduc- 
tion  of  Bone,  with  Special  Reference  to  the  Variable 
Portions  of  the  Maxillae,"  merits  the  closest  attention  of 
those  who  desire  to  understand  the  subject  of  which  it 
treats.  In  this  essay,  principles  are  announced  which  are 
not  only  valuable  in  leading  to  an  understanding  of  ne- 
crosis, but  which  are  really  in  advance  of  anything  relat- 
ing to  reproduction  of  bone  previously  presented. 

All  that  is  possible  should  be  done  to  save  the  natural 
teeth  and  all  parts  adjacent  to  them,  so  that  the  wearing 
of  artificial  dentures  may  not  become  necessary.  With 
the  teeth  made  safe  by  proper  treatment  and  restored  to 
usefulness  by  operations  successfully  performed,  and  with 
the  enamel  kept  clear  of  deposits,  each  smile  of  the 
patient  brings  to  view  organs  which  not  only  serve  the 
purpose  of  mastication  but  add  to  the  attractions  of  the 
wearer. 

Each  operation  ought  to  be  well  performed  at  every 
point,  and  be  made  fine  throughout,  regardless  of  the  fee 
expected,  and  the  gold  should  always  be  given  a  finely- 
finished  surface.  By  taking  the  necessary  care  and  time, 
beautiful  and  permanent  fillings  can  be  made;  the  success 
of  the  operator  be  assured  and  his  future  made  bright, 


PREFACE.  Vll 

— every  satisfactory  operation  benefiting   not  alone  the 
patient  but  not  less  the  faithful  practitioner. 

The  author  sincerely  hopes  that  these  Notes  will  serve 
the  purpose  of  aiding  operators  to  do  such  work  as  is  re- 
ferred to,  and  he  would  remind  all,  that  in  literature, 
sculpture,  painting,  and  music,  and  in  operations  such  as 
dentists  ought  to  perform,  it  is  not  the  aim  of  a  Dry  den, 
a  Michael  Angelo,  a  Raphael,  a  Beethoven,  or  a  Varney, 
to  write,  carve,  paint,  bring  forth  in  "  concord  of  sweet 
sounds,"  or  to  produce  in  gold,  that  which  requires  but 
little  time  and  skill,  and  is  simply  cheap  and  inartistic; 
it  is  the  endeavor  of  the  artist,  whatever  the  sphere  of  his 
efforts,  to  produce  the  perfect  and  beautiful. 

Marshall  H.  Webb. 
Lancaster,  Pa.,  U.  S.  A,, 
October  28,  1882. 


OPERATIVE  DENTISTRY. 


BY  operative  dentistry  is  meant  the  application  of  re- 
medial agents  for  the  correction  of  perverted  func- 
tion and  the  removal  of  abnormal  growths,  so  that  the 
elements  of  the  tissues  and  organs  may  be  normally 
reproduced  and  maintained;  the  observance  of  dentition 
throughout  its  course,  that  irregularity  of  the  teeth  may 
be  averted,  modified,  or  corrected ;  and  the  performance 
of  such  operations  as  shall  prevent  or  arrest  solution  of 
the  lime-salts,  or  decay. 


HISTOLOGY. 


SIN"CE  a  knowledge  of  the  histology,  as  well  as  of  the 
anatomy,  of  the  teeth  and  their  associate  parts  is 
necessary,  that  the  operator  may  discriminate  closely  be- 
tween the  different  phases  of  perverted  action  in  the 
tissues,  and  thus  be  able  to  remove  obstructions  to  nor- 
mal function,  a  description  of  the  minute  structure  of 
the  dentine,  cementum,  enamel,  pericementum,  and  pulp 
will  here  l)e  given,  preceded  by  some  brief  general  state- 
ments relating  to  the  elements  of  tissues,  development 
of  the  teeth,  and  the  structure  of  bioplasson  (protoplasm). 
The  elements  of  tissues  are  called  embryonal  corpus- 
cles, bioplasm,  or  medullary  bodies.  The  elements  of 
these  bodies  are  granules ;  those  of  granules,  molecules ; 
and  those  of  molecules  are  atoms.  Hence,  as  it  has  been 
graphically  described,  by  the  aggregation  of  atoms  in 
compliance  with  type  by  the  affinity  or  affinities  of  each 
when  awakened  and  engaged,  molecules  are  formed ;  in 
obedience  to  a  like  law  granular  aggregation  of  molecules 
is  brought  about;  and  then  the  elements  of  tissues — cor- 
puscles— are  constituted.  These  bodies,  formerly  so-called 
cells,  are  named  (and  properly)  in  accordance  with  the 
type  of  tissue  which  they  build.  In  nerve,  bone,  and 
muscle,  for  instance,  they  are  called  respectively  nerve- 
tissue  corpuscles  (ganglionic  corpuscles  and  axis  cylinders), 
bone-corpuscles  or  osteoblasts,  and  medullary  corpuscles. 

10 


NOTES  ON  OPERATIVE    DENTISTRY.  11 

Dentinal  and  enamel  elements  are  medullary  corpuscles 
or  "  odontoblasts." 

The  development  of  the  teeth,  succinctly  stated  by  Dr. 
Atkinson,  is  as  follows :  "  The  first  apparent  change  is 
called  the  granular  stage,  and  constitutes,  as  its  name 
implies,  an  accumulation  of  granules,  which  in  process  of 
time  becomes  the  secondary  stage,  called  the  papillary, 
which  merges  into  the  third  stage,  denominated  the  fol- 
licular. When  the  papules,  which  constitute  the  sides  of 
the  follicle,  have  increased  sufficiently  to  unite  and  close 
the  mouth  of  the  follicle  by  fusing  together,  we  have  the 
saccular  stage,  inclosing  the  germ  of  the  tooth,  called  the 
tooth-pulp,  consisting  of  two  planes  of  granular  bodies 
destined  to  calcification,  according  to  the  law  of  their 
production,  as  demanded  by  the  use  to  which  they  are 
assigned.  The  enamel  elements  calcify  immediately 
against  the  first  stratum  of  dentinal  elements,  towards  the  » 
periphery  of  the  pulp,  until  complete.  The  dentinal 
bodies  calcify  towards  the  center  of  the  pulp  until  the 
series  of  these  is  exhausted  by  calcification,  and  then  we 
say  that  the  tooth  is  fully  develoj^ed,  leaving  now  the  pulp 
in  the  pulp-chamber.  The  cementum  is  produced  in  like 
manner  by  characteristic  elements,  calcifying  from  the 
zonal  or  interglobular  layer  towards  the  periphery." 

In  1872,  Dr.  Carl  Heitzmann,  of  Xew  York,  discovered 
a  delicate  reticulum  of  living  matter  pervading  the  whole 
mass  of  bioplasson  (protoplasm),  and  he  very  soon  after- 
wards found  the  same  minute  structure  in  other  tissues  of 
the  animal  body,  mainly  epithelium  and  connective-tissue. 
Max  Schultze  described  the  delicate  ''thorns"  which 
pierce  the  cement-substance  between,  epithelial  bodies,  and 
connect  one  such  body  with  another  (Fig.  1,  ^,  in  1864, 
and  in  1873  Dr.  Heitzmann  found  that  these  thorns  are 


12 


NOTES    ON    OPERATIVE    DENTISTRY. 


Fig.   L* 


fibers  of  li\'ing  matter,  and  that  they  are  continuous  with 

the  reticulum  of  Hving  mat- 
ter in  the  epithehal  bodies 
themselves  [g,  Fig.  1) ;  he 
also  attributes  the  move- 
ment of  the  cilia  of  the 
ciliated  epithelium  to  the 
constant  action  of  this  same 
living  matter  throughout 
*  the  epithelial  body.  The 
cement-substance  in  all  epi- 
thelial and  endothelial  for- 
mations is  pierced  by  fibers 
of  living  matter,  as  illus- 
"'^  trated  between  the  epithe- 
lial bodies  shown  in  Fig.  1. 
Dr.  Heitzmann  found 
that  a  minute  lump  of  pro- 
toplasm, magnified  to  1000 
diameters,  "displays  a  mar- 
velously  complicated  struc- 
ture, which  essentially  can 
be  designated  to  be  reticula- 
ted in  nature."  When  Dr. 
Heitzmann  saw  "this  re- 
ticulum, with  its  points  of 
intersection,  changing  its 
shape,  growing  in  certain 
conditions,"     he     thought, 

"  Here  is  a  formation  in   the   protoplasm  which  is  pos- 


I'^iii  "I  I  i)'i'l  I  "I  11"  •-'""  iii-iir  a  tooth, 
magiiifidl  ;i.)Oiliiiiii(tcih;  <-.  H;it  cpitliclia  ;  6, 
r'iilH>irlHl  fijitlu-liiwii ;  t;  columnar  (;|iitlicliiiin  ; 
(/,  Max  S<-liult/,i;'H  ttioriis  ;  e,  coiinectivc'-tissiie 
corfMiwlcH  ;  /,  Hiiiall  vein  :  g,  rcticiiliuii  of  liv- 
ing rnattor;  //,  capillarj'  ;  i,  coniicctivc-tisHue 
biinillt'H. 


*The  drawinff.s  for  the  cuts  to  illustrate  epithelium  and  the  di8tri])ution 
of  livinj^  matter  in  dentine,  cernentum,  cnumfl,  etc.,  were  made  by  r>i"- 
C.  F.  W.  Bodeeker  from  sj)eciinens  whicli  hr  prfpiired. 


NOTES    ON    OPERATIVE    DENTISTRY.  13 

sessed  of  all  the  properties  that  are  necessary  for  the  con- 
dition of  living  matter,  viz.,  motion,  change  of  shape,  and 
groicth ;"  and  he  concluded  that  "  the  solid  nucleus,  the 
threads  emanating  from  the  nucleus,  the  granules  serving 
as  points  of  intersection,  and  the  investing  layer,  are  the 
real  formations  of  living  matter."  He  describes  the  net- 
like structure  of  protoplasm  thus :  "  The  nucleolus  is 
connected  with  the  wall  of  the  nucleus,  and  this  again 
with  the  granules  of  the  protoplasm  by  very  fine  threads, 
which  are  to  be  regarded  as  the  living  matter  of  the  pro- 
toplasm, while  the  fluid  contained  within  these  meshes  of 
living  matter  does  not  possess  the  property  of  life."  This 
net-like  structure  is  shown,  though  rather  indistinctly,  in 
the  protoplasmic  body  or  bone-corpuscle  illustrated  in 
Fig.  2,  6.  The  main  properties  of  living  matter  are  mo- 
tion and  reproduction.  Dr.  Heitzmann  and  his  pupils 
have  noticed  "  contraction  and  extension,  alternately,  in 
every  variety  of  protoplasmic  formation  ;  also  the  increase 
in  size  of  living  matter  (swelling  of  the  granules),  both 
in  the  physiological  process  of  propagation  and  in  the 
pathological  process  of  inflammation."  A  half-per-cent. 
solution  of  chloride  of  gold  imparts  a  violet  shade  to  liv- 
ing matter,  by  which  it  can  be  distinctly  recognized  with 
high  powers  of  the  microscope. 

Soon  after  Dr.  Heitzmann  discovered  the  net-like  struct- 
ure of  protoplasm,  he  observed  that  the  living  matter,  in 
the  form  of  a  reticulum,  was  present  in  all  the  four  varie- 
ties of  connective  tissue,  viz.,  myxomatous,  fibrous,  car- 
tilaginous, and  bony.* 

Dr.  C.  F.  W.  Bodecker,  of  New  York  City,  after  having 

*Dr.  Heitzmann  very  often  traces  the  fibers  of  living  matter  for  the 
benefit  of  his  pupils,  while  instructing  them  in  other  elements  of  tissue, 
and  it  was  the  author's  good  fortune  to  have  seen  them. 


14 


NOTES    ON   OPERATH^E   DENTISTRY. 


pursued  the  study  of  various  tissues  with  Dr.  Heitzmann 
(whose  pupil  he  was),  extended  his  researches  to  the  den- 
tal tissues ;  the  study  of  bone  had  prepared  him  for  the 
discovery  of  living  matter,  which  he  found  distributed 
throughout  the  dentine,  cementum,  and  enamel. 

In  studying  bone  Dr.  Bodecker  found  a  much  more 
delicate  net-work  of  canaliculi  than  other  observers  had 
thought  to  be  present.  He  found  that  "  the  lacunae  of 
bone-tissue  are  the  spaces  in  the  glue-giving  basis-sub- 
stance, each  of  these  spaces  containing  a  protoplasmic 
body,  with  a  distinctly  visible  net-like  arrangement,  to  be 
regarded  as  the  living  matter  of  the  protoplasm.  The 
basis-substance  of  bone  is  pierced  by  canaliculi,  which 
communicate  with  each  other  as  well  as  with  the  lacunae." 
*  *  *  *  "The  protoplasmic  bodies,  which  do  not  quite 
fill  the  lacunae,  send  offshoots  of  the  living  matter  into  the 
canaliculi." 

Fig.  2. 


CroMK-Bectioii  from  coiujia//t  butii  of  the  lower  jaw  of  a  man  about  thirty  yeare  of  age, 
jna^uified  1000  diaiueteni ;  a,  b,  aad  c,  protoplasmic  bodies  or  bone  ijorpUBcles. 

In  Fig.  2  are  shown  three  protoplasmic  bodies  or  bone- 
corpuscles;  from  the  offshoots  of  these,  fibers  of  living 
matter  are  distributed  through  the  light  reticulum  of  the 
baeis-Hubstance  of  the  bone.     "All  three  bone-corpuscles 


NOTES  ON  OPERATIVE  DENTISTRY.  15 

are  drawn  in  the  front  view,  as  seen  by  an  immersion-lens, 
magnifying,  with  the  eye-piece,  1000  times  linear.  We 
observe  in  the  center  of  the  protoplasmic  bodies  a  and  6, 
— a  shining,  oblong  nucleus  in  a,  and  a  round  one  in  6, 
in  which  the  nucleoli  are  not  distinctly  visible.  Around 
the  nuclei  we  see  a  narrow  seam,  traversed  by  numerous 
fine  threads,  which  are  cone-shaped.  Their  bases  are 
directed  towards  the  nucleus,  from  the  peripliery  of  which 
they  arise,  while  their  points  are  in  connection  \^^th  the 
nearest  granules  of  the  protoplasm.  Within  the  proto- 
plasmic substance  there  are  finer  and  coarser  granules, 
all  of  which  are  connected  with  one  another  by  very  fine 
threads." 

PREPARATION      OF      SPECIMENS.* 

The  method  which  Dr.  Bodecker  has  found  to  be  the 
best  for  the  preparation  of  bone,  dentine,  and  cementum 
for  microscopical  purposes  is  "  to  immerse  only  a  few 
teeth  in  a  large  vessel  with  a  considerable  amount  of 
chromic-acid  solution  of  the  strength  of  a  half  to  one  per 
cent.;  to  renew  the  same  every  third  or  fourth  day,  and 
add,  to  enforce  the  action  of  the  fluid,  very  small  quanti- 
ties of  dilute  hydrochloric  acid.  By  this  treatment  the 
teeth,  after  a  few  months,  become  dark  green  from  the 
reduction  of  the  chromic  acid  to  the  sesquioxide  of  chro- 
mium. This  method  is  doubtless  the  best  for  softenine: 
teeth,  both  human  and  animal,  when  still  in  the  jaw — 
wonderful  specimens  can  be  obtained  in  this  way  by  cut- 
ting bone  and  tooth  at  the  same  time — and  also  for  prepar- 
ing specimens  from  embryos,  in  order  to  study  the  history 

*From  an  essay  on  "The  Distribution  of  Living  Matter  in  Human 
Dentine,  Cement,  and  Enamel,"  by  Dr.  C.  F.  "W.  Bodecker,  read  before 
the  American  Dental  Association,  August,  1878. 


16  NOTES    ON    OPERATIVE    DENTISTRY. 

of  development  of  teeth.  This  method  is  highly  recom- 
mended, although  the  chromic  acid  softens  the  cement 
and  dentine  only  to  a  certain  depth,  so  that  a  tooth  kept 
ever  so  long  in  the  chromic  acid  solution  never  is  fit  to 
be  cut  through  in  its  whole  substance  at  one  time. 

"  The  sections  so  obtained  are  ready  for  staining  with 
carmine  or  hematoxylon  after  they  have  been  immersed 
in  and  washed  with  distilled  water ;  also  for  staining  with 
chloride  of  gold,  which  latter  may  be  done  in  the  fol- 
lowing way :  thin  sections,  after  having  been  washed  in 
distilled  water  for  twenty-four  hours  and  thus  freed  from 
the  remnants  of  chromic  acid,  are  to  be  placed  in  a  solu- 
tion of  chloride  of  gold  of  the  strength  of  half  of  one 
per  cent.,  by  means  of  glass  rods,  as  metals  must  be 
avoided  in  the  treatment  with  chloride  of  gold.  These 
sections  are  to  remain  in  the  solution  for  a  half  to  one 
hour,  and  must  then  be  thoroughly  washed  with  distilled 
water  and  exposed  to  daylight  for  several  days,  when  they 
are  ready  for  mounting  in  the  ordinary  way  in  glycerin 
diluted  with  fifty  per  cent,  of  distilled  water." 

"  The  only  method  which  enabled  me  to  obtain  speci- 
mens of  teeth  provided  with  all  hard  tissues  is  the  fol- 
lowing :  a  fresh  tooth,  or  one  kept  a  short  time  in  chromic- 
acid  solution,  is  sliced  under  water  by  a  watch-spring  saw, 
and  ground  as  thin  as  possible  upon  a  corundum-wheel 
of  a  lathe,  always  being  kept  under  water.  The  lamella 
thus  obtained  should  be  placed  in  a  large  quantity  of 
chromic-acid  solution  of  the  strength  of  half  of  one  per 
cent,  for  one  or  two  days,  with  the  view  of  hardening  the 
soft  parts  of  the  tooth  and  dissolving  the  lime-salts. 
After  this  the  specimen  may  be  stained  with  carmine, 
hematoxylon,  chloride  of  gold,  etc.,  as  above  described, 
and  mounted  in  dilute  glycerin." 


NOTES    ON    OPERATIVE    DENTISTRY.  ^7 

"  The  best  Miethod*  of  preparing  pulp-tissue  for  exami- 
nation is,  immediately  after  the  removal  of  the  tooth  from 
the  mouth,  to  place  it  in  an  aqueous  solution  of  chromic 
acid  of  one-half  to  one  per  cent,  in  strength.  To  this 
'mixture  may  be  added,  every  third  or  fourth  day,  to 
hasten  the  process  of  decalcification,  one  or  two  drops 
of  dilute  hydrochloric  acid.  It  is  important  to  use  a 
large  quantity  of  the  liquid — not  less  than  a  quart  for 
one  or  a  few  teeth — and  renew  the  same  at  least  every 
six  or  eight  days.  After  the  teeth  have  been  in  the 
chromic-acid  solution  a  few  weeks,  the  peripheral  por- 
tion of  the  dentine  will  become  sufficiently  soft  to  be 
cut  by  a  razor.  "When  the  hard  portions  of  the  dentine 
are  reached  by  the  cutting-instrument,  the  extraction  of 
the  lime-salts  must  again  be  continued  in  the  manner 
described  above  until  the  pulp-cavity  is  reached. 

"  Another  method  is  to  split  the  tooth  as  soon  as  possi- 
ble after  its  extraction  from  the  mouth  with  a  strong  pair 
of  excising-forceps.  The  teeth  best  adapted  for  this 
method  are  the  incisors,  canines,  and  bicuspids.  By  an 
experienced  manipulator  the  pulps  of  molars  can  be  ex- 
tricated from  their  inclosing  walls,  but  with  less  success 
than  in  the  teeth  before  mentioned.  In  splitting,  put  the 
cutting-edges  of  a  sharp  pair  of  excising-forceps  in  the 
longitudinal  direction  near  the  apex  of  a  single-rooted 
tooth,  then  make  a  sharp  and  quick  pressure,  when,  as  a 
rule,  the  tooth  will  split  into  halves  with  the  pulp-cavity 
exposed.  Immediately  moisten  the  pulp  with  a  solution 
of  chloride  of  sodium  in  water,  of  the  strength  of  about 
one-half    per   cent.,    and   then   remove   the   pulp.      The 

*  Essay  read  before  the  New  York  Odontological  Society,  March,  1882, 
by  Dr.  C.  P.  W.  Bddecker,  of  New  York,  on  the  "Minute  Anatomy, 
Physiology,  Pathology,  and  Therapeutics  of  the  Dental  Pulp." 

2 


18  NOTES    ON    OPERATIVE    DENTISTRY. 

greatest  care  must  be  taken  in  removing  the  fragments 
of  the  tooth  from  the  pulp-tissue  to  avoid  tearing  the 
organ,  which  greatly  alters  the  microscopical  aspect  of 
nerve-tissue.  If  the  pulp  is  to  be  stained  with  carmine, 
hematoxylon,  ftichsin,  hyperosmic  acid,  picro-indigo,  or 
chloride  of  gold,  etc.,  it  should  be  placed  in  the  staining- 
fluid  immediately  after  its  removal  from  the  hard  parts  of 
the  tooth. 

"  Among  the  reagents  mentioned  I  have  found  but  one 
of  considerable  value,  viz.,  the  solution  of  chloride  of 
gold  of  the  strength  of  one-half  of  one  per  cent.  This 
reagent  can  be  applied  to  fresh  pulps  as  well  as  to  very 
thin  sections  obtained  after  hardening  in  chromic  acid. 
These  specimens,  however,  must,  as  a  matter  of  course, 
be  careftilly  washed  with  distilled  ^vater  before  adding  the 
chloride-of-gold  solution.  This  reagent  may  be  allowed 
to  remain  in  contact  with  the  specimens  for  from  twenty 
to  thirty  minutes,  when  they  should  again  be  ^^'ashed  in 
distilled  water  and  exposed  to  daylight.  In  a  few  days 
fresh  specimens  will  assume  a  bright  violet  color,  while 
sections  which  have  pre\dously  been  in  a  chromic-acid 
solution  Vjecome  brownish-violet.  Osrnic  acid,  in  solu- 
tion of  one  per  cent,  in  strength,  renders  the  contours  of 
the  constituent  tissues,  and  especially  those  of  the  medul- 
lated  nerve-fibers,  more  distinct,  as  it  stains  the  nerve-fat 
dark  green.  Both  fresh  and  chromic-acid  specimens  may 
be  treated  with  osmic  acid.  Thin  sections  do  not  require 
more  than  an  hour's  exposure  to  this  reagent,  while  whole 
fresh  pulps  may  be  left  in  it  for  two  or  three  hours.  Ex- 
cept the  aramoniacal  solution  of  carmine,  which  is  known 
to  be  excellent  for  staining  certain  parts  of  the  tissue, 
I  would  not  lay  stress  upon  applying  any  of  the  other 
reagents  mentioned. 


NOTES    ON    OPERATIVE    DENTISTRY.  19 

"  If  we  ^vish  to  examine  the  pulp,  together  with  the  in- 
closing dentine,  or  a  pulp-stone,  the  specimen,  previously 
softened  by  chromic  acid,  must  be  imbedded  in  a  mixture 
of  paraffin  and  wax,  which  is  best  done  in  the  following 
manner :  place  the  softened  tooth  in  absolute  alcohol  for 
about  twenty-four  hours ;  then  prepare  a  box  made  of 
rather  thick  paper,  somewhat  larger  than  the  specimen ; 
warm  the  imbedding  mixture,  which  consists  of  about 
eight  parts  of  paraffin  and  one  of  white  wax,  until  it  is 
barely  liquid ;  pour  enough  of  it  into  the  paper  box  to 
about  half  fill  it ;  then  take  the  specimen  out  of  the  alco- 
hol, and  as  soon  as  it  begins  to  dry  place  it  in  the  paper 
box  and  pour  over  it  some  more  of  the  paraffin  and  wax, 
so  as  to  cover  it  completely.  But  care  must  be  taken  not 
to  have  the  imbedding  mixture  too  hot,  as  it  may  injure 
the  living  matter.  The  specimen  then,  after  the  mixture 
has  become  sufficiently  hard,  is  ready  for  cutting,  when 
very  thin  sections  can  easily  be  obtained. 

"  If  a  fresh  pulp  is  thin  enough  it  may,  immediately 
after  its  removal  from  the  split  tooth,  be  transferred  to 
the  slide,  with  the  addition  of  an  indifferent  fluid,  such 
as  the  solution  of  chloride  of  sodium,  etc.  But  a  slight 
and  careful  pressure  upon  the  cover  is  necessary  in  order 
to  spread  fresh  specimens.  The  fresh  pulps  of  lower 
incisors,  being  the  thinnest,  are  the  best  adapted  for  ex- 
amining the  system  of  blood-vessels.  In  a  short  time, 
however,  these  blood-vessels  fade  away,  and  the  specimen 
becomes  unfit  for  preservation.  Isolated  pulps  may  be 
placed  between  two  plates  of  velvet-cork,  and  thus  cut 
into  thin  sections  with  the  razor.  I  would  recommend 
dilute  glycerin  as  the  best  preser^dng-fluid  for  pulp-speci- 
mens I  have  found." 


20  NOTES    ON    OPERATIVE    DENTISTRY. 

DENTINE. 

"  We  know"  (states  Dr.  Bodecker,  in  the  essay  from 
which  we  have  previously  quoted)  "  that  the  basis-sub- 
stance or  matrix  of  the  dentine  is  analogous  to  that  of 
bone,  viz.,  glue-giving,  and  at  the  same  time  infiltrated 
with  lime-salts.  We  learn  from  the  researches  of  E.  E'eu- 
noiann  that  the  basis-substance  is  denser  on  the  walls  of  the 
tubuli,  and  more  resistive  to  the  action  of  strong  acids, 
which  cause  the  appearance  of  a  sheath  around  each  tu- 
bule after  the  solution  of  the  intermediate  substance  of  the 
matrix  between  the  tubuli.  Analogous  relations  also  exist 
in  bone-tissue,  in  which  the  basis-substance  is  decidedly 
denser  on  the  walls  of  the  lacunae  and  Haversian  canals. 

"With  low  powers  w^e  cannot  see  anything  but  the  tu- 
buli, which  I  propose  to  term  hereafter  '  dentinal  cana- 
liculi.'  These  canaliculi,  as  is  well  known,  run  in  curved 
sigmoidal  lines  from  the  boundary  of  the  pulp-cavity  to 
the  periphery  of  the  dentine ;  they  are  directed  obliquely 
upward  in  the  crown,  and  assume  a  more  horizontal  di- 
rection in  the  region  of  tlie  neck,  while  in  the  root  they 
remain  horizontal  or  sometimes  turn  downward  to  a 
varying  extent.  Besides  the  main  sigmoidal  curvature, 
each  individual  canaliculus  exhibits  a  more  or  less  wavy 
course  in  its  way  through  the  dentine,  and  the  individual 
curvatures  are,  as  a  rule,  very  marked  on  the  outer  pe- 
riphery of  the  dentine." 

*  *  *  *  "  On  specimens  treated  with  chloride  of  gold, 
the  fibers  and  their  delicate  ofltshoots  show  a  distinct 
violet  color,  characteristic  of  living  matter  within  pro- 
toplasmic formations,  while  the  space  between  the  fiber 
and  the  wall  of  the  canaliculus  remains  unstained,  and 
the  basis-substance  between  the  tubuli  only  assumes  a 
slight  violet  tinge." 


NOTES    ON    OPERATIVE    DENTISTRY, 


21 


"  Longitudinal  sections  of  dentine,  stained  with  car- 
mine or  chloride  of  gold,  if  examined  with  high  powers 
— from  1000  to  1500  diameters  (immersion  lens) — exhibit 
the  following: 

''  The  canaliculi  of  the  dentine  run  in  a  more  or  less 
wa\y  course  through  the  basis-substance,  and  are,  as  a 
rule,  bifurcated  only  on  the  periphery  of  the  dentine, 
towards  both  enamel  and  cementum.  Each  canaliculus 
contains   a   central,  slightly-beaded  fiber,  which   on   its 

Fig.  3. 


TB 


Cross-section  of  root  of  molar.  Stained  with  half-per-cent.  sulution  of  chloride  of  gold. 
Magn.  1200  diam.  D,  dentine;  TB,  cement  (tooth-bone);  a  a,  protoplasmic  bodies  of  the 
cement,  branching  and  uniting;  b,  dentinal  fibers,  with  their  transverse  offshoots;  c  c, 
ramification  of  dentinal  fibers  and  their  union  with  the  offshoots  of  cement-corpuscles. 

Union  between  dentine,  D,  and  cement,  TB;  aa,  cement-corpuscles  with  large,  branching 
offshoots  connected  with  one  another  as  well  as  with  the  dentine-fibers,  6,  at  the  bifurcation 
of  the  latter,  c  c. 

whole  periphery  sends  delicate  thorn-like  elongations 
through  the  light  space  between  the  central  fiber  and 
the  wall  of  the  canaliculus.     The  thorns  are  distinctly 


22  NOTES    ON    OPERATIVE    DENTISTRY. 

conical,  their  bases  being  attached  to  the  dentinal  fibers, 
and  their  points  directed  towards  the  basis-substance. 
The  smallest  thorns  spring  in  an  almost  vertical  direc- 
tion from  the  dentinal  fiber,  while  somewhat  larger  oft- 
shoots  may  run  obliquely  through  the  basis-substance, 
and  directly  unite  neighboring  fibers  with  one  another 
in  the  vicinity  of  the  enamel  and  cementum. 

"The  basis-substance  shows  a  distinct  net-like  struc- 
ture. The  light  spaces  surrounding  the  dentinal  fibers 
send  delicate  elongations  into  the  basis-substance,  in 
which,  through  repeated  branching,  a  light  net-work  is 
established,  the  meshes  of  which  contain  the  decalcified 
glue-giving  basis-substance.  The  fiiijest  offshoots  of  the 
dentinal  fibers  can  be  traced  only  into  the  mouths  of  the 
elongations  of  the  canaliculi;  on  the  periphery  of  the 
latter,  owing  to  their  great  delicacy,  the  offshoots  are  lost 
to  sight.  Coarser  offshoots  of  the  dentinal  fibers,  at  the 
localities  mentioned  before,  traverse  the  basis-substance 
within  its  light  net-work,  at  the  same  time  uniting  den- 
tinal fibers  directly,  and  sending  slender,  conical  offshoots 
into  the  light  net-work  of  the  basis-su1jstance. 

"The  dentinal  fibers  are  either  in  direct  connection 
with  coarser  offshoots  of  the  protoplasmic  bodies  of  the 
cementum,  or  the  light  net-work  of  the  basis-substance 
of  the  dentine  is  in  communication  with  that  of  the  basis- 
substance  of  the  cementum.  The  latter  condition  pre- 
vails on  the  periphery  of  the  neck  of  the  tooth,  where 
the  basis-substance  of  the  dentine  is  not  pierced  by  the 
larger  offshoots  of  the  dentinal  fibers,  but  only  by  a  deli- 
cate net>work,  through  which  the  connection  l)etween 
dentine  and  cementum  is  indirectly  estaljlished. 

"  Where  the  dentine  is  in  contact  with  the  pulp,  the 
dentinal  fibers   directly  communicate  with   the   odonto- 


NOTES    ON   OPERATIVE   DENTISTRY. 


23 


blasts  (John  Tomes)  in  a  growing  tooth,  and  with  the  pro- 
toplasmic bodies  of  the  pulp  in  a  fully-developed  condi- 
tion, where  no  regular  odontoblasts  can  be  seen. 

"In  cross-sections  of  dentine  the  dentinal  canaliculi  are 
visible  in  the  shape  of  round  or  oblong  holes ;  the  center 
of  each  is  occupied  by  the  dentinal  fiber,  which  has  the 
shape  of  a  small,  roundish  dot.  Again,  we  see  that  the 
periphery  of  the  dentinal  canaliculus  is  sharply  marked, 
and  repeatedly  interrupted  by  light  otfshoots  leading  into 
the  light  net-work  which  pierces  the  basis-substance  be- 
tween the  canaliculi.  The  central  fibers  look  very  dis- 
tinct and  dark  violet  in  specimens  stained  with  chloride 


Fio.  4. 


Fio.  5. 


h 


CroBS-sectionof  dentine  of  incisor.  Stained 
with  half-per-cent.  solution  of  cliloride  of 
gold.  Main  mass  of  dentine.  M:i);n.  2000 
diam.  a  a,  dentinal  canaliculi  with  the 
central  dentinal  flher;  c  c,  the  latter  with 
star-like  offshoots,  the  basis-suhstance  be- 
tween the  canaliculi  pierced  by  a  delicate, 
light  net-work,  h  b. 


Cross-section  of  dentine  of  incisor.  Stained 
with  half-per-cent.  solution  of  chloride  of 
gold.  View  from  outer  periphery  of  dentine 
near  enamel.  Magn.  2000  diam.  «  a,  den- 
tinal canaliculi  with  the  central  dentinal 
fibers,  c  c,  the  latter  with  star-like  offshoots  ; 
the  tiapis-substancc,  b  b,  between  the  canal- 
iculi, pierced  by  a  delicate,  light  net-work. 


of  gold,  and  send  slender,  conical,  radiated  otfshoots 
through  the  surrounding  dentinal  canaliculi  respectively, 
towards  the  mouth  of  the  light  interruptions  in  their  walls. 
"  In  directly  transverse  sections,  one,  two,  or  some- 
times even  three  such  otfshoots  can  be  seen  in  a  star-like 
arrangement.  Each  oftishoot  springs  with  a  broad  base 
from  the  central  dentinal  fiber,  while  its  pointed  end  is 
always  directed  towards  the  perforation  in  the  wall  of 
the   canaliculus,  where,    as   a   rule,  it   is   lost   to   sight. 


•24  NOTES    ON   OPERATIVE    DENTISTRY, 

Slightly  oblique  sections  of  the  canaliculi  exhibit  both 
transverse  and  longitudinal  projections  of  the  dentinal 
fibers.  In  such  an  oblique  section  we  may  succeed,  by 
cautiously  changing  the  focus,  in  seeing  star-like  radiated 
offshoots  up  to  five  in  number,  all  arising  from  a  single 
dentinal  fiber, 

"  Towards  the  boundary  between  dentine  and  enamel, 
and  dentine  and  cementum,  as  is  well  known,  the  dentinal 
canaliculi  ramify,  and,  according  to  their  ramifications 
also,  the  dentinal  fibers  bifurcate,  becoming  thinner  the 
nearer  to  the  surface  of  the  dentine.  Both  longitudinal 
and  transverse  sections  of  this  part  of  the  dentine  show 
details  identical  with  the  main  mass,  the  only  difierence 
being  that  near  the  periphery  the  fibers  are  more  delicate 
and  more  closely  packed  together, 

"In  some  teeth  I  have  met  on  the  periphery  of  the 
dentine  of  the  crown  with  the  so-called  'interglobular 
spaces'  (Czermak),  which  may  be  considered  as  remnants 
of  the  embryonic  condition  of  the  dentine.  They  repre- 
sent lacunte  of  greatly  varying  sizes,  bounded  by  curved 
lines,  the  convexities  of  which  are  directed  towards  the 
central  cavity.  These  spaces  sometimes  contain  proto- 
plasm,— that  is  to  say,  embryonal  elements  which  have 
not  been  transformed  into  basis-substance  and  not  calci- 
fied. The  denthial  fibers  enter  the  protoplasmic  bodies, 
and  each  fiber  is  united  with  the  net-work  of  the  proto- 
plasm by  means  of  delicate  thorn-like  projections.  At 
other  times  the  basis-substance  of  the  dentine  is  developed 
within  the  interglobular  spaces,  but  devoid  of  Ume-saltK, 
In  this  instance  the  dentinal  fibers,  without  investment 
and  without  changing  their  course,  pierce  the  basis-sub- 
stance and  send  oflshoots  to  this  through  the  surrounding 
light  spaces." 


NOTES    ON    OPERATIVE    DENTISTRY.  25 

C  E  M  E  N  T  U  M. 

"  It  has  long  been  known  that  there  exists  a  striking 
analogy  between  the  structures  of  the  cementum  and  bone. 

"  Within  the  basis-substance  of  the  cementum  there 
are  numerous  branching  spaces,  in  correspondence  witli 
the  lacunae  of  bone.  The  offshoots  of  these  spaces  in  the 
cementum,  like  the  spaces  themselves,  are  very  marked 
in  dry  specimens,  because  of  their  being  filled  with  air. 
In  chromic-acid  specimens,  on  the  contrary,  the  offshoots 
are  much  less  prominent,  and  less  prominent  the  more 
thoroughly  the  decalcification  has  been  efiected.  No  es- 
sential difference  is  noticeable  between  the  lacunfe  and 
canaliculi  of  ordinary  bone  and  those  of  the  cementum ; 
in  both  tissues  there  exists  a  great  variety  as  to  the 
general  arrangement,  the  size  of  the  lacunae,  and  the 
number  and  ramifications  of  their  offshoots. 

"  The  walls  of  the  lacuuEe  and  the  coarser  offshoots,  if 
viewed  with  a  highly  magnifying  lens  (immersion,  1000 
to  1500  diam.),  appear  interrupted  on  their  peripheries 
by  light  spaces,  which  lead  into  a  light,  delicate  net-work, 
piercing  the  whole  basis-substance  to  such  an  extent  that 
only  the  meshes  have  to  be  considered  as  the  fields  of 
calcified  glue-giving  basis-substance. 

"'  Each  lacuna  contains  a  protoplasmic  body  with  a  cen- 
tral nucleus, — the  cement-corpuscle.  The  nucleus  some- 
times is  relatively  large  and  surrounded  only  by  a  narrow 
seam  of  protoplasm ;  while  in  some  small  lacunae  a  body 
of  the  appearance  of  a  nucleus  is  present  without  a  notice- 
able amount  of  surrounding  protoplasm.  The  net-like 
structure  of  both  the  nuclei  and  the  protoplasm  is  plainly 
visible  in  all  cement-corpuscles.  From  the  periphery  of 
each    corpuscle    conical   offshoots    arise,   the    coarser   of 


26  NOTES  ON  OPERATIVE  DENTISTRY. 

wMch  penetrate  into  the  larger  offshoots  of  the  lacunae, 
while  the  finest  offshoots  of  the  protoplasm  traverse  the 
light  rim  between  the  walls  of  the  lacunas  and  the  pe- 
riphery of  the  protoplasm,  being  directed  towards  a  light 
interruption  on  the  boundary  of  the  lacunae. 

"  Cement-corpuscles,  on  the  average,  are  round  or 
spindle-shaped  bodies,  the  long  diameter  of  which  corre- 
sponds to  the  direction  of  the  lamellae.  •  In  teeth  of  juve- 
nile and  middle-aged  persons  we  meet  with  cement-cor- 
puscles surpassing  three  or  four  times  the  size  of  ordinary 
ones,  in  which  two  or  three  nuclei  are  visible.  Instead  of 
multinuclear  bodies,  a  number  of  medullary  nucleated 
elements  may  fill  a  large  lacuna,  all  these  elements  being 
connected  with  one  another  by  very  delicate  threads. 
The  longitudinal  diameter  of  such  large  lacunae  is  some- 
times arranged  radiately,  therefore,  perpendicularly  to 
the  direction  of  the  lamellae. 

"Numerous  cement-corpuscles  send  broad  and  branch- 
ing offshoots  through  the  basis-substance  in  a  perpendicu- 
lar or  oblique  direction  to  the  lamellae,  and  not  infrequently 
a  direct  union  is  established  between  t^^'o  or  three  cement- 
corpuscles  by  means  of  such  large  offshoots  (Fig.  3,  a  a). 

"  In  some  teeth  broad,  spindle-shaped  spaces  pierce  the 
cementum  in  a  radiated  direction,  all  of  which  contain 
protoplasm  with  delicate  offshoots  directed  towards  the 
net-work  in  the  basis-substance,  l^ay,  sometimes  medul- 
lary spaces  traverse  the  lamelUe  in  difterent  directions, 
which,  besides  a  varying  number  of  medullary  elements, 
contain  capillary  blood-vessels,  evidently  in  connection 
vnth  the  capillaries  of  the  periosteum.  These  formations 
may  be  considered  as  remnants  of  the  embryonic  condi- 
tion of  the  cementum,  and  are  never  present  in  large 
numbers.     All  protoplasmic  formations  within  the  cemen- 


NOTES    ON    OPERATIVE    DENTISTRY.  27 

turn,  though  varying  greatly  in  shape,  agree  in  being 
connected  with  one  another  by  the  delicate  net-work 
which  pierces  the  basis-substance. 

"  On  the  periphery  of  the  cementum,  on  the  line  of 
the  connection  with  the  periosteum,  the  net-work  of  the 
protoplasm  is  usually  very  broad,  and  the  fields  of  the 
basis-substance  show  a  prevailing  globular  appearance. 
Also,  numerous  spindled-shaped  protoplasmic  bodies  are 
seen  in  connection  with  the  cementum  in  an  oblique 
arrangement,  forming  the  transition  into  the  structure 
of  the  periosteum.  Between  the  calcified  cementum  and 
the  striated  connective-tissue  of  the  periosteum  there 
often  exists  a  narrow  zone,  occupied  by  closely-packed 
spindle-shaped  protoplasmic  bodies  only.  In  the  perios- 
teum itself  there  are  less  numerous,  partly  nucleated 
protoplasmic  bodies,  between  which  the  fields  of  an 
apparently  homogeneous  glue-giving  basis-substance  are 
seen. 

"  The  connection  batween  dentine  and  cementum  is 
established  either  by  a  gradual  change  of  one  tissue  into 
the  other,  without  a  distinct  line  of  demarkation,  or  there 
exists  a  boundary  formed  by  a  more  or  less  marked  wavy 
line,  presenting  irregular,  bay-like  excavations ;  lastly, 
it  occurs  that  between  the  l)ay-like  excavations  and  the 
dentine  there  is  interposed  a  stratum  of  the  structure  of 
cementum,  with  a  gradual  change  of  the  tissue  of  the 
former  into  that  of  the  latter. 

"  Where  a  gradual  change  takes  place,  the  dentinal 
canaliculi  show  irregular,  mainly  spindle-shaped  enlarge- 
ments, which  stand  in  the  direction  of  the  dentinal  cana- 
liculi themselves,  or  run  obliquely  through  the  basis-sub- 
stance of  the  cementum.  The  distal  end  of  such  a 
epindle  is,  as  a  rule,  in  connection  with  a  regular  lacuna 


28 


NOTES    ON    OPERATIVE    DENTISTRY. 


of  the  cementum,  or  with  an  analogous  formation  of  a 
neighboring  dentinal  canaliculus.  Many  of  the  latter 
simply  pass  into  the  light,  delicate  net-work  character- 
istic of  the  basis-substance  of  cementum.  The  dentinal 
fiber  is  in  direct  union  with'the  protoplasm  which  fills  the 

Fig.  6. 


TB 


Transition  of  dentine,  D,  into  cement,  TB,  with  an  intermediate  layer  of  cement-struct- 
ure, a,  bifurcating  dentine-fibers,  in  union  with  elongated  ceinent-corpuBcles,  6  and  c;  the 
latter  imbedded  in  the  basis-substance,  d  ;  between  this  and  the  regular  cement,  with  proto- 
plasmic bodies,  e,  the  wavy  boundary  ;  all  cement-corpuscles  united  with  one  another  by  large 
offshoots,  /  and  <;.    Magnified  1200  diameters. 


spindle-shaped  spaces,  or  it  is  lost  to  sight  upon  entering 
the  net-work  of  tlie  basis-substance  of  the  cementum. 

"  Where  a  boundary  with  bay-like  excavations  is  present 
between  dentine  and  cementum,  spindle-shaped  enlarge- 
ments of  the  dentinal  canaliculi  may  be  seen,  much  smaller 
than  in  the  former  instance.     The  majority  of  the  dentinal 


NOTES    ON    OPERATIVE    DENTISTRY.  29 

canaliculi,  however,  reach  the  l)oundary  of  the  cementum 
atter  repeated  hifurcations,  bv  which  both  the  calibers  of 
the  canahcuU  and  their  central  fibers  are  gradually  diniin- 
iehed  in  size. 

"  A  connection  of  the  dentinal  fibers  with  the  coarser 
offshoots  of  the  cement-corpuscles  is  often  observed.  The 
light  net-work  of  the  basis-substance  of  the  dentine  always 
passes  into  that  of  the  cementum.  Not  very  rarely,  also, 
on  the  bottom  of  a  bay-like  excavation,  partly  nucleated 
protoplasmic  bodies  are  present,  into  which  the  dentinal 
fibers  inosculate.  The  connection  between  these  and  the 
coarser  offshoots  of  the  cement-corpuscles  under  these 
circumstances  is  established  b}'  such  intervening  proto- 
plasmic bodies. 

"  For  the  designation  of  the  protoplasmic  formations 
between  the  dentine  and  enamel,  and  dentine  and  cemen- 
tum, I  choose  the  term  '  interzonal  layer,'  as  first  proposed 
by  Dr.  W.  H.  Atkinson." 

NECK     OF     T  0  0  T  II. 

"  There  are  certain  peculiarities  about  the  minute 
anatomy  of  the  neck  of  the  human  tooth  which,  so  far 
as  I  can  judge  from  the  literature  within  my  reach,  have 
not  been  heretofore  mentioned."  *  *  *  * 

"  The  cementum  around  the  neck  forms  a  narrow  layer 
which  is  cut  off  obliquely  at  the  place  of  junction  with 
the  enamel.  The  cementum  and  enamel  in  this  situation 
— ^being  of  the  same  width — are  separated  by  a  boundary 
which  runs  from  the  outer  periphery  obliquely  down- 
wards to  the  dentine.  This  relation  I  have  found  in  the 
majority  of  teeth,  and  it  is  only  exceptionally  that  I  have 
met  with  cementum  regularly  overlapping  the  enamel. 
The  cementum  on  the  neck  is  built  up  by  delicate  prisms. 


30 


NOTES    ON    OPERATIVE    DENTISTRY. 


or  spindles,  arranged  vertically  to  the  surface  of  the  den- 
tine. The  prisms  represent  the  fields  of  the  basis-sub- 
stance, and  are  separated  from  one  another  by  light  rims, 
holding  beaded  fibers,  or  traversed  by  delicate  vertical 
threads.  In  transverse  sections,  v^hen  the  prisms  are  cut 
obliquely,  they  exhibit  irregular,  opaque  fields  separated 
from  each  other  by  light  rims. 

Fig.  7. 


D    P 


Anomalous  formation  of  cementum  on  the  neck  of  a  human  tooth.  D,  D,  dentine  ;  N,  N, 
cementuni  on  neck  of  tooth,  with  spindle-shaped  or  prismatic  fields  of  basis-substftnce  ;  D,  P, 
depression  in  the  cementum  of  the  neck,  filled  with  elements  of  periosteum,  surrounded  up- 
ward by  a  zone  of  regularly  developed  cementtun.    Magnified  12fK)  diameters. 

''  These  formations  closely  resemble  the  protoplasmic 
bodies  of  the  periosteum  next  to  the  cementum  alluded 
to  in  the  former  chapter ;  hence  I  do  not  hesitate  to  con- 
sider the  bony  formation  on  the  neck  as  being  produced 
by  calcification  of  the  osteoblasts  of  the  periosteum. 
The  cementum  on  the  neck  of  the  tooth  is  devoid  of 
lamellae  and  lacuna.',  which  appear  deeper  below,  together 


NOTES    ON    OPERATIVE    DENTISTRY.  31 

with  all  the  characteristic  features  of  the  fully-developed 
structure  of  the  cementum.  The  lamelhe  become  the  more 
distinct,  and  the  lacume,  with  their  contents  (the  cement- 
corpuscles),  the  more  numerous,  the  broader  the  diameter 
of  the  layer  of  the  cementum. 

"  The  outer  surface  of  the  cementum  is  covered  on  its 
upper  part  with  epithelial  elements,  in  close  resemblance 
with  those  of  Nasmyth's  layer  of  the  enamel.  This  layer 
turns  over  into  the  epithelial  coat  of  the  gum.  Further 
down,  the  cementum,  though  still  endowed  with  proper- 
ties characteristic  of  the  neck  of  the  tooth,  is  surrounded 
by  the  fibrous  connective-tissue  of  the  periosteum." 

ENAMEL. 

"■  The  best  specimens  of  enamel  for  examination  I 
obtained  by  grinding  fresh  teeth,  and  staining  them  for 
one  hour  with  the  half-per-cent.  solution  of  chloride  of 
gold,  as  mentioned  in  the  description  of  methods  for  the 
examination  of  teeth  in  general. 

"  In  longitudinal  sections  we  ^lo-  8. 

.  see  delicate,  beaded  fibers, which    .ga^^gjgg^jpE^aBI^;><^- 
occupy  the  central  portion   of 
the  interstices  between  the  en- 
amel-rods.    These  fibers  I  pro- 
pose hereafter  to  term  the  '  en- 

.    _  Ldiigitudiiial  section   of   enamel,    a, 

amei-IlDerS.  enamel-rods,    traversed    by    prevailing 

i,  -rn  •      1  n  1  •  vertical  spaces ;  6, enamel-fibem, branch- 

"From    such    a    fiber    arise  ^^g  ^..^  ..avtiy  uniting  through  delicate 

very     minute       conical      fibrillar,    °^'''°"*^-    Numerous  fine  thorns  of  the 
•'  '    fibers  directed  towards  the  light  inter- 

which   traverse    the    rims    be-  ™i>tion8  within  the  rods.    Magnified 

1200  diameters. 

tween  the  fiber  and  the  neigh- 
boring outlines   of   the   rods,  and  fade  away  from  the 
moment  they  enter  the  latter.     The  columns  of  the  basis- 
substance  are  themselves  pierced  by  delicate  canaliculi. 


32  NOTES    ON    OPEKATIVE    l>BNTIbTl{Y. 

ruuning  in  an  almost  vertical  direction  through  the' 
enamel-rods,  regularly  enough  to  give  the  apf)earance  of 
squares,  although  these  are  much  smaller  than  usually 
represented  in  the  hooks.  In  the  midst  of  a  minute 
square  light  canals  are  seen,  not  infrequently  running 
parallel  with  the  outlines  of  the  enamel-rod.  The  square 
fields  thus  produced  hy  the  rectangular  crossing  of  light 
channels  look,  under  the  power  of  1200  diameters,  finely 
granular.  In  specimens  not  fully  decalcified  it  is  impos- 
sihle  to  decide  whether  there  is  a  light  net-work  within 
the  enamel  prisms  analogous  to  that  in  the  basis-suhstance 
of  the  dentine  and  cementum,  or  whether  the  granular 
appearance  is  merely  due  to  the  deposition  of  lime-salts. 
In  thoroughly  decalcified  specimens  of  enamel,  however, 
such  as  were  first  made  by  Dr.  Frank  Abbott,  there  is 
no  difficulty  in  seeing,  with  high 
powers,  the  reticular  structure  of 
protoplasm.  I  am  indebted  to  the 
above-named  observer  for  having 
first  drawn  my  attention  to  this 
fact. 

"  Cross-sections    of    the    enamel 

which  we  obtain  also  in  longitudinal 

,    sections  of  the  tooth,  on  account  of 

Cross-section   through   enamel.  ' 

a,  rods  of  enamel,  partly  exhibit-  ^]^q  different  directious  of  the  bun- 

ing  formations  like  nuclei ;  h,  c,  rf, 

ligiit  interstices  between  the  rods,  dlcs  of  the  Guamel-rods,  plainly  ex- 

traversed     by     delicate     beaded        ...        ,         .  ,  I'liijiii 

fibers,  e,  or  by  vertical  thorns,  hibit  ths  irrcgular  polyhcdral  fields 
Magnified  2rK3o  dian.eters.  ^^.  ^^^  g^amel-rods.    The  light  iuter- 

stices  between  the  polyhedral  fields  contain  in  many  in- 
stances delicate,  beaded  fibers,  surrounding  the  polyhedral 
fields  of  the  enamel-rods.  The  fibers,  if  cut  transversely, 
have  the  appearance  of  dots,  and  connect  with  one  another 
directly  or  by  means  of  intervening  delicate  threads. 


NOTES  ON  OPERATIVE  DENTISTRY.  33 

"  Extremely  fine  thorns  traverse  in  a  vertical  direction 
the  light  space  between  two  neighboring  enamel-rods, 
even  where  a  fiber  is  not  visible.  These  threads  are 
identical  with  the  delicate  thorns  first  described  by  Max 
Schultze,  in  1864,  in  the  cement-substance  of  epithelial 
formations. 

"  The  rods  of  the  enamel  on  an  average  are  half  the 
diameter  of  the  columns  of  the  basis-substance  in  dentine ; 
therefore  four  columns  of  the  former  will  correspond  to 
two  of  the  latter,  and  consequently  two  dentinal  fibers 
will  answer  to  four  enamel-fibers.  Sometimes  in  the 
cross-section  of  an  enamel-rod  I  met  with  roundish  form- 
ations occupying  the  center  of  the  rod,  one  or  two  in 
number,  which,  owing  to  a  denser  granulation  and  a  sur- 
rounding shell,  have  the  appearance  of  nuclei.  The 
enamel-fibers  run  a  very  straight  course  towards  the 
surface,  and  are  here,  on  the  average,  a  trifle  thicker  than 
near  the  boundary  of  the  dentine. 

"  The  outermost  surface  of  the  enamel  is  covered  with 
flat  epithelia  (J^asmyth's  membrane),  which  in  the  trans- 
verse section  have  the  appearance  of  shallow  spindles ;  not 
infrequently  there  also  occurs  a  stratified  epithelium  on 
the  surface  of  the  tooth.  The  enamel-fibers  are  in  con- 
nection with  these  epithelial  bodies,  which,  if  detached, 
show  delicate  oft'shoots  adhering  in  regular  intervals — the 
broken  enamel-fibers.  Sometimes  the  surface  of  the 
enamel  is  coated  with  a  thin,  uniform  layer  of  protoplasm, 
with  regularly  scattered  nuclei.  In  such  an  instance 
single  epithelia  are  not  traceable,  though  scarcely  any 
doubt  can  arise  about  the  epithelial  nature  of  this  layer. 

"  At  the  place  of  junction  of  the  enamel  with  the  den- 
tine a  direct  connection  is  often  seen  between  the  enamel- 
and  dentine-fibers.      The  latter,  through  repeated  bifur- 

3 


34 


NOTES    ON    OPERATn''E    DENTISTRY. 


cations,  lieing  closely  brought  together,  continue  their 
course  into  the  enamel-fibers  without  any  interruption. 
The  direction  of  the  fibers  of  the  two  tissues,  however,  is 
almost  never  identical,  inasmuch  as  the  enamel-rods,  and 
consequently  the  enamel-tibers,  as  a  rule,  owing  to  their 
wavy  course  in  this  situation,  are  obliquely  intercepted 
upon  the  dentine. 

"  We  can  very  often  trace  dentinal  fibers  up  into  the 
enamel  in  a  varying  distance,  without  a  distinct  union 
between  the  enamel-  and  dentine-fibers,  as  the  former  do 
not  reach  the  surface  of  the  dentine,  but  terminate  above 


Union  of  dentine  with  enamel.  D,  dentine ;  E,  enamel :  a  a,  dentinal  fibers,  being  in 
union  with  large  protoplasmic  bodies,  6  c  d,  or  directly  running  into  enamel-fibers,  e  g.  The 
latter  often  are  lost  in  the  delicate  irregnlar  net-work  on  the  bottom  of  tlie  enamel,  /  /. 
Magnified  12fX)  iliaint'tern. 

its  level  in  different  heights,  while  the  zone  close  above 
this  is  occupied  by  a  delicate,  irregular  net-work,  anal- 
ogous to  that  of  the  dentine.  Here  no  rods  of  enamel 
are  visible,  either  in  longitudinal  or  transverse  sections. 


NOTES   ON    OPERATIVE    DENTISTRY.  35 

but  with  low  powers  of  the  microscope  only  a  finely-gran- 
ular layer  is  presented, 

"  In  many  places  the  dentinal  canaliculi  upon  entering 
the  enamel  suddenly  become  enlarged,  and  form  more  or 
less  distinctly  spindle-shaped  ca\dties  of  greatly  varying 
diameters,  analogous  to  the  spindle-shaped  enlargements 
on  the  boundar}'  of  the  cementum.  These  enlargements 
run  either  in  the  main  direction  of  the  dentinal  canaliculi 
or  deviate  obliquely.  They  invariably  contain  protoplas- 
mic bodies,  which  plainly  show  the  reticular  structure, 
and  sometimes  contain  one  or  more  compact  clusters,  to 
be  considered  as  nuclei.  The  spindle-shaped  protoplasmic 
bodies,  on  their  proximate  ends,  are  in  direct  connection 
with  the  terminations  of  the  dentinal  fibers  which  have 
arisen  from  their  repeated  bifurcations,  while  on  the  distal 
ends  they  may  show  delicate  fibers,  \'iz,,  enamel-fibers,  or 
delicate  conical  thorns,  traversing  the  light  space  between 
the  surface  of  the  protoplasmic  body  and  the  wall  of  the 
cavity.  These  thorns  are  lost  to  sight  on  passing  into  the 
net-work  at  the  bottom  of  the  enamel.  In  some  places, 
especially  on  the  cusps,  the  spindle-shaped  enlargements 
of  the  dentine-fibers  are  quite  numerous,  and  of  an  almost 
uniform  size  and  direction,  forming  regular  rows  of  spindles 
within  the  enamel.  In  the  teeth  of  younger  individuals 
the  spindle-shaped  enlargements  are  comparatively  larger 
and  more  regular  than  in  the  teeth  of  old  j)eople. 

"  The  boundary  line  between  the  dentine  and  enamel  is 
either  straight  or  slightly  wavy,  and  with  more  or  less 
deep  bay-like  excavations,  analogous  to  those  on  the 
boundary  between  dentine  and  cementum.  The  concavi- 
ties of  the  bays  are  directed  towards  the  dentine.  In  this 
interzonal  layer  at  the  bottom  of  the  bays  we  meet  with 
fibers  occupying  the  curved  spaces  between  dentine  and 


36  NOTES    ON    OPERATIVE    DENTISTRY. 

enamel,  or  we  will  see  in  a  correspondingly  bent  direction 
protoplasmic  bodies  directly  connected  with  the  dentinal 
fibers  downwards,  and  with  the  enamel-fibers  upwards. 
In  specimens  stained  with  chloride  of  gold  the  dentine  is 
always  much  deeper  in  color  than  the  enamel,  hence  the 
relations  described  are  very  plainly  marked  on  such  speci- 
mens." 

P  E  R  I  C  E  M  E  N  T  U  M.* 

"  The  pericemetum  *  *  *  is  a  formation  of  connective 
tissue,  identical  with  the  periosteum  which  covers  all 
bones.  It  consists  of  a  layer  interposed  between  the  roots 
of  the  teeth  and  their  corresponding  bony  alveoli,  and  is 
common  to  both.  It  is  continuous  with  the  connective 
tissue — the  so-called  sub-mucous  layer — of  the  gum,  and 
with  the  periosteum  of  the  maxilhe.  Its  fibers  are  con- 
nected with  the  cementum  of  the  root  as  well  as  with  the 
wall  of  the  alveolus." 

"  The  course  taken  by  the  connective-tissue  bundles  is 
slightly  wavy  and  oblicjue,  starting  from  the  cementum 
and  running  upward  towards  the  alveolus.  The  bundles 
of  this  tissue  are  very  dense,  without  many  decussations. 
The  parallel  direction  of  the  bundles  begins  to  change 
into  a  diverging  one  at  about  the  height  of  the  border  of 
the  socket,  where  the  bundles  became  coarser,  decussate, 
and  thus  produce  the  elastic  connective-tissue  cushion 
termed  the  gum. 

"  From  the  anatomical  disposition  of  the  pericementum 
conclusions  may  be  drawn  as  to  its  physiological  action. 
It  is  obvious  that  the  relatively  soft  and  elastic  layer  be- 
tween the  two  bony  formations — cementum  and  alveolus — 

*"0n  Pericementum  and  Pericementitis."  By  C.  F.  W.  Bodecker, 
M.D.,  D.D.S.,  Dental  Cosmos,  1879. 


NOTES    ON    OPERATIVE    DENTISTKY.  37 

is  designed  to  lessen  the  concussion  upon  the  jaw-bones 
during  mastication.  The  obUque  direction  of  the  con- 
nective-tissue bundles  is  the  most  favorable  for  the  sus- 
pension of  the  tooth  mthin  its  socket,  as  the  Imndles 
correspond  to  the  funnel  shape  of  the  socket,  in  the  center 
of  which  is  situated  the  conical  root  of  the  tooth.  The 
elasticity  of  the  layer  of  pericementum  admits  of  a  slight 
degree  of  motion  of  the  roots ;  hence  we  understand  the 
formation  of  facets  on  the  approximal  surfaces  of  the 
crowns  of  the  teeth  in  crowded  maxillary  arches. 

"My  specimens  represent  two  varieties  of  pericemen- 
tum,— one  of  a  reticular  structure,  termed  myxomatous; 
the  other  is  altogether  fibrous.  The  myxomatous  variety  I 
have  met  with  as  a  rule  in  young  individuals.  It  consists 
of  delicate  fibers,  or  bundles  of  fibers,  in  a  net-like  arrange- 
ment, which  in  many  instances  are  supplied  with  round  or 
oblong  nuclei  at  the  points  of  intersection.  The  meshes 
contain  either  a  hyaline,  apparently  structureless,  some- 
times finely-granular  basis-substance,  or  they  hold  proto- 
plasmic bodies  provided  with  a  varying  number  of  nuclei. 
The  nearer  to  the  cementum  the  narrower  is  the  myxo- 
matous reticulum,  and  the  smaller  therefore  are  the  inclosed 
protoplasmic  bodies.  The  latter,  in  the  immediate  vicinity 
of  the  cementum,  stand  in  more  or  less  reerular  rows, 
entirely  analogous  to  the  protoplasmic  bodies  around  the 
developing  bony  tissue,  known,  since  Gegenbaur,  as  '  os- 
teoblasts.' Some  of  the  meshes  of  the  myxomatous  tissue 
are  considerably  larger  and  contain  multinuelear  proto- 
plasmic bodies,  termed  '  myeloplaxes '  by  Robin,  of 
Paris ;  giant  cells  by  R.  Yirchow,  of  Berlin,  and  myeloid 
cells  by  English  authors.  Other  meshes  hold  fat  globules, 
which,  in  specimens  preserved  and  hardened  in  a  solution 
of  chromic  acid,  very  often  contain  closed  spaces,  so-called 


38  NOTES    ON    OPERATIVE    DENTISTRY. 

vacuoles.  The  myxomatous  reticulum  is  traversed  by 
numerous  blood-vessels,  mainly  capillaries  and  veins,  some 
of  which  can  be  seen  entering  the  medullary  spaces  of 
the  compact  bone  of  the  wall  of  the  alveolus,  and  in  con- 
nection with  the  capillary  system  of  the  cancellous  portion 
of  the  alveolus.  I  have  met  with  but  few  nerve  fibers  in 
my  specimens. 

"Fig.  11  illustrates  a  portion  of  the  myxomatous  variety 

Fig.  11. 


m-- 

■■              /     .        ■:.         ' 

l',f;;!: 

/                '  '   ■      / 

ssiL_:- 

■:...J...-1^--L.U 

./.. 


n 


.AJra 


Pericementum  of  myxomatous  structure.  D,  dentine  ;  C,  cementum  of  neck;  P,  peri- 
cementum ;  M,  multinuclear  protoplasmic  body ;  V,  capillary  blood-vessel ;  F,  fat  globule 
■with  a  vacuole.     Magnified  500  diameters. 

of  pericementum  as  shown  A\itli  a  relatively  low  power. 
High  amplification  of  the  microscope  plainly  demonstrates 
the  delicate  reticular  structure  of  all  protoplasmic  bodies; 
the  reticulum-  being  visible  not  only  in  the  contents  of  the 
meshes,  but  also  within  the  fibers  of  the  myxomatous 
reticulum.  The  latter  feature  is  recognizable  best  on 
specimens   deeply  stained  with   chloride  of  gold.     The 


NOTES    ON    OPERATIVK    J)ENT1STIIY,  39 

apparently  structureless  or  indistinctly  granular  myxo- 
matous basis-substance,  held  in  the  meshes  of  the  myxo- 
matous reticuhun,  proves  to  be  a  reticular  structure  just 
as  well  as  the  protoplasm  itself. 

"  The  second  variety  of  pericementum  is  built  up  by 
fibrous  connective-tissue,  which  prevails  in  adults  and 
persons  in  advanced  age.  The  bundles  of  the  fibrous 
connective-tissue  may  be  uniform  in  width  throughout 
the  whole  pericementum ;  or  there  exists  a  zone  of  myxo- 
matous or  indistinctly  fibrous  character  close  around  the 
cementum.  The  bundles  are  built  up  by  a  number  of 
fibers,  which  hold  a  varying  number  of  protoplasmic 
bodies ;  as  a  rule,  more  numerous  the  nearer  to  the 
cementum.  On  the  latter  there  may  be  found  rows  of 
osteoblasts  or  scattered  protoplasmic  bodies  alternating 
with  bundles  of  a  delicate  connective-tissue,  which  are 
directly  attached  to  the  cementum.  In  a  few  instances  I 
have  seen  rows  of  osteoblasts  the  refi'acting  power  of 
which  was  consideral)ly  augmented.  Such  corpuscles 
looked  shining  and  structureless,  evidently  on  account  of 
a  deposition  of  lime-salts.  The  fibrous  variety  of  the 
pericementum  also  contains  fat-globules,  sometimes  in 
surprisingly  large  quantities. 

"  High  magnifying  powers  of  the  microscope  reveal  a 
structure  of  the  fibrous  connective-tissue,  as  follows :  The 
fibers,  a  certain  number  of  which  combine  in  the  forma- 
tion of  a  bundle,  are  delicate  spindles,  directly  connected 
with  one  another  at  their  pointed  ends.  These  spindles  are 
separated  from  one  another  by  a  narrow  layer  of  a  light 
substance,  to  the  presence  of  which  Tomsa,  of  Kiev,  Rus- 
sia, first  drew  attention,  and  for  which  he  proposed  the 
term  '  cement-substance.'  This  substance  is  doubtless 
kindred  to  the  gluey  basis-substance  which  mainly  builds 


40  NOTES    ON    OPERATIVE    DENTISTRY. 

up  the  spindles  of  tlie  connective-tissue.  The  interstices 
between  the  spindles  are  traversed  in  a  vertical  direction 
by  extremely  minute  threads  every  way  analogous  to  the 
thorns  in  the  cement-substance  surrounding  epithelial  ele- 
ments. These  threads  in  many  instances  are  visible  in 
specimens  hardened  by  the  chromic-acid  solution;  they 
become  very  plain  when  thin  sections  have  been  immersed 
in  a  half-per-cent.  solution  of  chloride  of  gold  for  one  or 
two  hours,  or  until  the  specimen    has    assumed  a  dark 


Fig.  12. 


fT  PL 

Pericementum  of  fibrous  structure.  D,  cementum  of  root;  PL,  pericementum,  tho 
fibers  of  which  are  built  up  by  spindles,  in  longitudinal  section  ;  PT,  pericementum,  the 
elementary  spindles  of  which  are  finer  and  cut  ol)liqueIy  ;  h,  protoplasmic  bodies,  either  so- 
called  connective-tissue  corpuscles  or  so-called  osteoblasts.     Magnified  120)  diameters. 

violet  color.  If  the  stain  be  complete,  we  also  recognize 
that  the  spindles  are  not  homogeneous,  as  they  look  in 
fresh,  unstained  specimens,  but  are  rather  traversed  by  a 
delicate,  dark  violet  reticulum,  the  points  of  intersection 
of  which  are  slightly  thickened,  and  thus  represent  gran- 
ules.    (See  Fig.  12). 

"  Between  the  spindles  of  the  basis-substance  proto- 
plasmic bodies  are  seen — tlie  formerly  so-called  connective- 


NOTES    ON   OPERATIVE    DENTISTRY.  41 

tissue  cells.  Some  of  these  bodies  exhibit  shining,  com- 
pact, oblong  nuclei,  with  a  certain  amount  of  surrounding 
protoplasm,  while  others  are  devoid  of  nuclei,  and  split 
into  spindle-shaped  or  polygonal  lumps,  which  in  size  and 
shape  fully  correspond  to  the  elementary  formations  of 
the  fibrous  basis-substance.  Where  there  is  a  central 
nucleus,  it  is  invariably  bounded  by  a  light  rim,  which  is 
pierced  by  radiating  thorns.  The  latter  connect  the  cir- 
cumference of  the  nucleus  with  the  granules  of  the  pro- 
toplasm next  to  the  nucleus.  Tlie  protoplasm  under  all 
circumstances  exhibits  the  well-known  reticular  structure. 
From  the  periphery  of  a  protoplasmic  body,  each  being 
surrounded  by  a  light  rim,  minute  threads  spring  forth 
and  run  into  the  reticulum  within  the  spindles  of  the 
basis-substance,  The  same  relations  are  seen  on  proto- 
plasmic bodies  next  to  the  cementum, — the  so-called  osteo- 
blasts. The  offshoots  of  these  formations  run  partly  to 
the  spindles  of  the  basis-substance  and  partly  into  the 
light  reticulum  within  the  cementum.  In  some  instances, 
between  the  cementum  and  the  osteoblasts  there  is  inter- 
posed a  small  layer  of  fibrous  basis-substance  in  the  shape 
of  delicate  slender  spindles.  The  walls  of  the  capillaries, 
which  consist  of  a  single  layer  of  endothelia,  are  also  con- 
nected with  the  neighboring  spindles  of  the  basis-sub- 
stance by  means  of  delicate  threads,  which  traverse  the 
light  rim  around  the  l)lood-vessels, — the  so-called  perivas- 
cular space.  Lastly,  such  offshoots  run  also  into  the  light 
reticulum  of  the  bone-tissue,  where  the  pericementum  is 
attached  to  the  wall  of  the  alveolus." 

*  *  *  *  "In. its  juvenile  condition  the  pericementum 
represents  a  myxomatous  connective-tissue,  the  fibrous  por- 
tion of  which  is  relatively  scanty,  while  the  protoplasmic 
portion  prevails.      In  this  instance  two  varieties  of  basis- 


42  NOTES    ON    OPERATIVE    DENTISTRY. 

substance  occur,  viz.,  the  fibrous,  building  up  the  reticulum, 
and  the  myxomatous,  filling  a  certain  portion  of  the  meshes. 
This  condition  arises,  first,  from  the  indiiFerent  or  embryo- 
nal tissue,  not  only  in  the  pericementum,  but  in  all  forma- 
tions of  connective-tissue  which,  when  fully  developed, 
exhibit  a  fibrous  structure.  The  only  way  to  explain  the 
formation  of  the  myxomatous  tissue  is,  that  a  part  of  the 
protoplasm  constituting  the  embryonal  elements  remains 
unchanged,  a  part  is  transformed  into  spindles  of  the 
myxomatous  reticulum,  and  a  part  into  myxomatous  basis- 
substance." 

*  *  *  *  "  The  myxomatous  tissue  as  such  never  changes 
directly  into  a  fibrous  one,  but  must  first  be  reduced  into 
its  embryonal  or  protoplasmic  condition,  and  from  this  in 
turn  fibrous  connective-tissue  may  arise.  The  latter  pro- 
cess is  explained  by  the  splitting  and  elongation  of  the  pro- 
toplasmic bodies  into  spindles,  which  become  solidified;  in 
other  words,  the  lifeless  fluid  is  transformed  into  a  gluey 
basis-substance. 

"  At  no  time  has  the  reticulum  of  the  living  matter 
been  interrupted  .  or  torn ;  the  pericementum  has  never 
ceased  to  be  a  tissue  either  in  its  embryonal,  myxomatous, 
or  fibrous  condition.  On  the  theory  here  explained,  all 
changes  in  inflammatory  processes  of  the  pericementum 
may  be  easily  understood." 

THE    MINUTE    STRUCTURE    OF    NORMAL   PULP-TISSUE. 

"  If  we  examine  a  thin  longitudinal  or  transverse  sec- 
tion of  the  pulp  with  low  powers  of  the  microscope  (200 
diameters),  we  recognize  a  large  number  of  blood-vessels 
and  bundles  of  medullated  nerve-fibers.  The  majority  of 
these  blood-vessels  are  capillaries ;  the  veins  are  less  nu- 
merous, and  arteries  are  scarce.     In  many  pulps  we  find 


NOTES    ON    OPERATIVE    DENTISTRY.  43 

no  arteries  at  all ;  in  others  a  limited  number,  very  often  in 
the  midst  of  the  medullated  nerve-bundles.  The  medul- 
lated  nerve-bundles  mostly  run  in  a  longitudinal  direction, 
but  not  infrequently  we  observe  smaller  bundles,  or  single 
medullated  nerve-fibers,  diverge  from  the  longitudinal  di- 
rection, running  obliquely  through  the  pulp-tissue. 

"  In  transverse  sections  of  the  pulp  we  meet  with  arteries, 
veins,  and  capillaries, — the  first  cut  across,  the  others  dis- 
tributed in  all  directions.  The  bundles  of  medullated 
nerve-fibers  are  seen  most  distinctly  in  transverse  sections. 
They  often  hold  in  their  interstitial  tissue  capillary  vessels 
and  arterioles,  which  also  appear  in  transverse  section.  In 
very  thin  sections  it  often  happens  that  the  nerve-fibers 
fall  out,  and  then  we  see  a  roundish,  empty  space,  bounded 
by  the  sharply-defined  external  perineurium.  The  absence 
of  an  endothelial  coat  renders  such  spaces  easily  recogni- 
zable in  distinction  from  blood-vessels. 

"  The  main  mass  of  the  pulp,  as  seen  with  low  powers,  is 
composed  of  a  delicate  fibrous  reticulum,  containing  a 
large  number  of  bright,  shining  corpuscles.  Longitudinal 
sections  in  many  instances  exhibit  delicate  fibrous  bundles 
scattered  throughout  the  reticular  structure  of  the  pulp, 
mostly  in  the  neighborhood  of  large  blood-vessels  and 
nerve-bundles.  Pulps  composed  of  a  fibrous  connective- 
tissue  only  are  rather  exceptional,  and,  as  it  seems,  are 
without  any  relation  to  the  age  of  the  person.  They  are 
probably  the  result  of  morbid  processes.  Toward  the 
outer  surface  of  the  pulp  the  reticular  structure  is,  as  a 
rule,  denser  than  in  the  middle  portions.  This  peripheral 
part  is  surrounded  by  a  wreath  of  elongated  formations 
arranged  in  a  radiating  manner  all  around  the  pulp — the 
so-called  '  odontoblast  layer.' 

"  Higher  powers  of  the  microscope  (500  to  600  diameters) 


44 


NOTES    ON    OPERATIVE    DENTISTRY. 


reveal  a  minute  reticular  structure,  consisting  of  delicate 
fibers  of  anastomosing  bioplasson  cords,  with  very  small 
oblong  nuclei  at  their  points  of  intersection.  The  mesh- 
spaces  inclosed  b}'  this  reticulum  either  look  pale  and 
finely  granular  throughout,  or  there  is,  besides  the  pale 
granular  substance,  a  bright  yellowish  body,  either  homo- 
geneous or  granular,  of  the  size  and  aspect  of  a  nucleus. 
The  number  of  the  latter  formations  varies  greatly  in 

Fig.  13. 


Segment  of  the  pulp  of  a  first  molar.  Longitudinal  section.  Jlf,  myxomatous  connec- 
tive tissue  ;  V,  vein  ;  C,  capillary  blood-vessel ;  iV,  bundle  of  iiiedullated  nerve-fibers  ;  F, 
terminal  non-niedullated  inrve-fibers  ;  B,  bioplasson  layer,  containing  the  terminations  of 
the  nerves  ;  0,  layer  of  nieduUary  corpuscles,  termed  odontoblasts.  Magnified  2.50  diame- 
ters. 

different  pulps.  "Where  bundles  of  a  fibrous  tissue  tra- 
verse the  reticulum,  there  the  latter  blend  with  the  former. 
In  the  fibrous  bundles,  besides  the  delicate  fibrillae,  we  see 
scanty  and  small  oblong  nuclei. 


NOTES    ON    OPERATIVE    DENTISTRY.  45 

"  As  mentioned  before,  the  fibrous  connective-tissue  pre- 
vails at  the  periphery  of  tlie  larger  blood-vessels  and 
nerve-bundles.  In  transverse  sections  these  nerve-bundles 
invariably  exhibit  a  distinct  fibrous  sheath  containing 
oblong  nuclei — the  so-called  external  perineurium.  The 
nuclei  imbedded  in  the  sheath  do  not  project  above  the 
level  of  the  sheath,  as  is  plainly  observable  on  empty  ones 
where  the  fibres  have  fallen  out,  while  the  endothelia 
of  ])lood-vessels  of  any  description  in\'ariably  protrude 
toward  the  inclosed  space,  thus  affording  an  excellent 
means  of  distinction  between  blood-vessels  and  empty 
nerve-sheaths. 

"  The  arteries  are  characterized  l)y  the  presence  of  a  layer 
of  smooth  muscles,  outside  of  which  is  seen  a  slight 
fibrous  coat.  The  layer  of  smooth  muscles  necessarily 
thickens  the  walls  of  the  blood-vessels,  thus  rendering 
them  easily  recognizable  in  transverse  sections.  The  veins 
are  marked  by  their  large  caliber  and  a  fibrous  coat,  being 
at  the  same  time  filled  with  blood-corpuscles.  The  capil- 
laries are  composed  of  a  single  endothelial  layer,  which  is 
separated  from  the  adjacent  reticulum  by  an  extremely 
delicate  light  rim.  They  are  either  found  empty  or  con- 
taining a  few  blood-corpuscles. 

"  In  longitudinal  sections  the  meduUated  nerve-fibers 
show  the  well-known  fiuted  double  contour  of  considera- 
ble refraction  (the  sheath  of  Schwann).  Inside  of  this  is 
the  myelin  (nerve-fat),  concealing  the  central  axis-cylinder. 
Schwann's  sheath  exhibits  delicate  oblong  or  spindle- 
shaped  nuclei,  and  external  to  this  we  observe  a  very 
delicate  layer  of  fibrous  connective  tissue — '  the  internal 
perineurium.'  In  cross-sections  of  the  nerve-bundles  a 
more  or  less  circular  group  of  meduUated  nerve-fibers  is 
seen,  each  of  which  in  its  center  exhibits  the  axis-cylinder 


46  NOTES  ON  OPERATIVE  DENTISTRY. 

in  the  shape  of  a  roundish,  glistening  dot,  the  single 
nerve-fibers  being  separated  from  one  another  by  the  deli- 
cate internal  perineurium,  l^ot  infrequently  capillary  and 
arterial  blood-vessels  are  met  with  between  the  nerve- 
fibers  which,  at  the  periphery  of  the  bundles,  blend  with 
the  nucleated  sheath  of  the  external  perineurium. 

"  As  to  lymphatics  of  the  pulp,  I  can  say  that  in  some 
specimens  I  have  seen  branches  of  vessels  of  the  size  of 
veins  without  an  adventitial  coat,  being  composed  of  large, 
flat,  slightly-protruding  endothelia.  These  vessels  I  be- 
lieve to  be  lymphatics,  as  they  contained  a  finely-granular 
coagulated  albumen,  scanty  granular  corpuscles,  and  a 
very  limited  number  of  blood-corpuscles.  As  to  the  dis- 
tribution of  lymphatics,  I  must  abstain  from  positive 
statements. 

"  At  the  periphery  of  the  pulp  the  delicate  reticulum  con- 
stituting the  pulp-tissue  is  very  dense,  audits  small  meshes 
are  supplied  with  numerous  corpuscles  looking  like  nuclei. 
In  this  layer  we  meet  with  only  very  narrow  capillary 
blood-vessels.  The  outer  surface  of  this  layer  is  bounded 
by  radiating  rows  of  shining  corpuscles  of  the  size  and 
appearance  of  nuclei.  These  rows  are  separated  from  one 
another  in  a  longitudinal  direction  by  light  rims,  in  which 
delicate  fibrilhe  can  be  frequentl}^  observed. 

"  In  chromic-acid  specimens  stained  with  carmine,  or, 
still  better,  in  those  treated  with  chloride  of  gold,  high 
powers  (1000  to  1200  diameters)  reveal  an  extremely  mi- 
nute reticular  structure  pervading  all  formations  of  the 
pulp-tissue.  It  is  this  structure,  that  of  bioplasson  as  well 
as  basis-substance,  that  C.  Heitzmann  discovered  in  1873. 
('  Untersuchungen  iiber  das  Protoplasma,  Sitzungs-Be- 
richte  der  Kaiserlichen  Academic  in  Wien.')  Starting 
from  the  center  of  a  mesh-space,  we  see  a  body  like  a 


NOTES   ON    OPERATIVE    DENTtSTRY.  47 

nucleus,  either  homogeneous  and  apparently  destitute  of 
structure,  or  witli  the  appearance  of  a  vesicle  with  a  dis- 
tinct, bright  wall.  Inside  the  hollow  nucleus  we  see  a 
varying  number  of  bright  granules,  interconnected  with 
one  another  as  well  as  with  the  inclosing  wall  by  means  of 
delicate  filaments.  Around  the  nucleus  a  minute  light 
rim  is  seen,  which  again  is  traversed  by  radiating  fila- 
ments connecting  the  nucleus  with  the  extremely  delicate 
grayish  reticulum  pervading  the  light  basis-substance  con- 
tained in  the  mesh-spaces  of  the  fibrous  net-work.  The 
delicate  reticulum  in  the  basis-substance  is  recognizable, 
even  though  the  central  nucleus  be  absent.  The  fibrous 
or  bioplasson  net-work  which  incloses  the  mesh-spaces 
also  shows  a  delicate  reticulum  in  connection  with  the 
nuclei  at  the  points  of  intersection.  Thus,  all  coarser 
reticular  structures,  as  well  as  the  fields  of  basis-substance, 
are  traversed  by  an  extremely  delicate  reticulum,  which 
C.  Heitzmann  claims  to  be  living  matter  proper.  In  thi.>* 
view  I  fully  concur,  and,  so  far  as  my  experience  goes,  I 
would  mention  that  inflammation  in  general,  as  well  as 
that  of  the  dental  pulp,  cannot  be  understood  unless  the 
presence  of  living  matter  throughout  all  formations  of  bi- 
oplasson as  well  as  basis-substance  is  admitted.  It  is  this 
matter  which  grows  and  leads  to  a  new  formation,  so 
strikingly  shown  in  inflammation.  I  may  add  that  fibrillae 
of  living  matter  are  directly  connected  with  the  blood- 
vessels by  means  of  delicate  offshoots  penetrating  the  light 
rim  around  the  blood-vessels  called  the  '  perivascular 
space.' 

"  The  formations  at  the  periphery  of  the  dental  pulp, 
termed  '  odontoblasts '  by  J.  Tomes,  and  which  by  some 
observers  have  been  considered  as  epithelial-like  forma- 
tions, under  high  amplifications  exhibit  the  following : 


48  NOTES    ON    OPERATIVE    DENTISTRY. 

"  Longitudinal  fields,  somewhat  resembling  epithelia, 
border  the  pulp  in  a  radiatorj  direction.  Such  a  field 
may  appear  in  the  shape  of  a  finely-granular  bioplasson 
or  basis-substance,  in  which  there  are  imbedded  oblong 
nuclei  in  varying  numbers.  The  nuclei  exhibit  coarse 
granules  and  a  dense  reticulum  of  living  matter,  while  the 
elongated  fields  inclosing  the  nuclei  exhibit  pale  granules 
and  a  delicate  bioplasson  reticulum.  Between  these  latter 
formations  a  delicate  light  rim  is  seen,  wherein  we  ob- 
serve sometimes  broad,  sometimes  delicate,  fibrillse  in 
connection  with  the  reticulum  of  neighboring  formations, 
accompanied  by  delicate  conical  offshoots,  which  penetrate 
the  surrounding  rims  at  right  angles.  In  many  instances 
these  formations  between  the  odontoblasts  can  be  followed 
into  the  dentinal  fibers,  lodging  in  the  midst  of  the  den- 
tinal canaliculi. 

"  It  is  obvious,  from  what  I  have  seen,  that  the  odonto- 
blasts furnish  the  matrix  for  the  basis-substance  of  the 
dentine,  whereas  the  dentinal  fibers,  being  formations  of 
living  matter,  originate  between  the  odontoblasts.  When 
studying  secondary  dentine  I  described  and  depicted  a 
specimen  corroborating  this  assertion.  {Dental  Cosmos, 
vol.  xxi.,p.  412). 

"  The  manner  in  which  the  bioplasson  of  the  odonto- 
blasts is  transformed  can  be  understood  only  on  the  basis 
provided  by  the  researches  of  C.  Ileitzmann  (loc.  cit.),  who 
claims  that  the  li([uid  held  in  the  meshes  of  the  reticulum 
of  living  matter  is  rendered  solid  and  glue-yielding  by  a 
chemical  process,  while  the  living  reticulum  itself  re- 
mains unchanged,  and  merely  becomes  invisible  because 
it  has  nearly  the  same  refracting  power  as  the  basis-sub- 
stance. Where  the  refracting  power  varies  enough,  the 
formations  of  living  matter  remain  distinctly  perceptible. 


NOTES    ON    OPERATIVE    DENTISTRY. 


49 


Fio.   14. 


Such  is  the  case  with  the  dentinal  j&bers  and  their  trans- 
verse conical  oftshoots  within  the  dentinal  canaliculi. 

"  In  sufficiently  stained  ehloride-of-gold  specimens  of  a 
nine-months'  fetal  pulp  I  have  observed  that  the  medul- 
lated  nerve-fibers,  upon  approaching  the  periphery  of  the 
pulp,  are  destitute  of  their 
myeline  sheath,  and  now,  be- 
ing bare,  the  axis-cylinders 
split  into  numerous  extremely 
delicate  beaded  fibrill^e — the 
'  axis  fibrillte.'  They  are 
marked  by  a  dark  violet 
color,  and  run  in  the  light 
rims  between  the  rows  of  the 
odontoblasts  near  the  pulp- 
tissue  proper,  and  are  con- 
nected with  the  odontoblasts 
by  means  of  delicate  conical 
offshoots.  In  some  instances 
I  have  observed  that  these 
axis  fibrillfe  terminated  in 
knob-like   extremities.      But    „ 

Segment  of  the  pulp  ot  a  teiiipoiary  tooth, 

whether   the  nerve-fibers  di-  sfai^e^  ^ith  chloride  of  goia.  m,  myxoma- 
tous connective-ti^sue ;     N,   terminal  non- 
rectly     anastomose     with     the   medullated    nerve-flbers,    in     a    unifonnly 
.  granular  bioplaeson  layer;  0,  rows  of  me- 

dentinal     fibers    I    am    unable   dullary  corpuscles,  termed  odontoblasts ;  F; 
X  mi      J.  •     J  •  X  dentinal  fibers  between   the    odontoblasts ; 

to  say.        I  hat  an  indirect  con-  d,  dentine.     Magnified  1200  diameters. 

nection  of  the  two  is  estab- 
lished by  the  intervening  reticulum  of  li^^ng   matter  I 
positively  assert. 

"  The  results  of  my  researches  of  the  normal  pulp  are  as 
follows : 

"  I.     Tlie  dental  pulp  is  a  variety  of  connective-tissue 
termed  myxomatous,  representing  an  embryonal  form  of 

4 


50  NOTES    ON    OPERATIVE    DENTISTRY. 

it.  Pulp-tissue,  therefore,  is  a  remnant  of  embryonal 
tissue,  lasting  in  some  instances  throughout  life,  and 
kindred  to  tho^^e  formations  termed  '  adenoid  tissue.' 

"  II.  The  myxomatous  tissue  of  the  pulp  is  intermixed 
with  a  delicate  fibrous  connective-tissue  in  varying  quan- 
tities. Pulps  entirely  or  nearly  built  up  by  fibrous  con- 
nective-tissue probably  are  not  to  l)e  considered  physi- 
ological. 

"  in.  The  pulp-tissue  is  traversed  by  a  close  system  of 
blood-vessels,  viz.:  arteries,  veins,  and  capillaries.  Arteries 
are  not  invariably  found  in  the  pulp,  but  they  are  by  no 
means  of  exceptional  occurrence.  Lymphatics  in  small 
numbers  are  also  present. 

"  rV.  The  pulp-tissue  is  richly  supplied  with  nerves, 
which,  in  the  shape  of  bundles  of  medullated  nerve-fibers, 
traverse  the  myxomatous  tissue.  Toward  the  periphery 
of  the  pulp  they  lose  their  myeline  sheaths,  become  non- 
medullated,  and,  in  the  shape  of  minute  beaded  fibrillar, 
branch  between  the  odontoblasts. 

"  V.  The  odontoblasts  at  the  peripherj^  of  the  pulp  are 
elongated  bioplasson  formations  with  rows  of  nuclei. 
They  are  medullary  corpuscles  such  as  we  see  wherever  a 
new  tissue  arises  from  a  former  one.  They  build  up  the 
basis-substance  of  the  dentine  by  solidification  (transfor- 
mation into  glue,  and  infiltration  with  lime-salts).  The 
reticulum  of  living  matter  traversing  the  odontoblasts 
remains  unchanged  in  the  basis-substance  of  the  den- 
tine. 

"  VI.  The  dentinal  fi])ers  originate  between  the  odonto- 
blasts. Being  formations  of  living  matter,  they  are  in 
direct  connection  with  the  reticulum  of  living  matter — 
first  of  the  odontoblasts  and  afterwards  of  the  basis- 
substance  of  the  dentine.     The  connection  between  the 


NOTES    ON   OPERATIVE    DENTISTRY.  51 

ultimate  nerve-fibrillee  and  dentinal  fibers  is  very  probably 
an  indirect  one  by  means  of  the  intervening  reticulum  of 
living  matter." 


THE  DECIDUOUS  TEETH-PREVENTION  OF 
IRREGULARITY  AND  DECAY. 


r  j  ^H  H]  deciduous  teeth  should  be  kept  in  place  till  dis- 
placed  by  the  advancing  permanent  ones,  but  it  is 
sometimes  necessary  to  remove  decay  and  fill  cavities  in 
them  that  they  may  be  preserved.  In  most  cases,  however, 
they  should  be  extracted  when  devitalization  of  the  pulp 
occurs,  and  particularly  when  abscess  has  appeared,  for 
the  reason  that  solution  and  absorption  of  the  tissues  of 
the  roots  of  these  teeth  (as  the  permanent  advance  and 
push  upon  them)  does  not  normally  take  place  after  the 
death  of  the  pulp,  and  absorption  is  necessary  that  mal- 
position of  the  permanent  teeth  may  be  prevented. 

The  first  permanent  molar  should  not  be  extracted  after 
the  second  has  been  fully  erupted,  except  to  correct  an 
irregularity ;  and  when  the  extraction  of  one  of  these  teeth 
is  decided  upon  (particularly  if  one  or  more  of  the  others 
are  pulpless),  it  is  best,  in  many  cases,  to  remove  them  all, 
as  the  spaces  are  then  more  likely  to  be  closed  and  their 
places  supplied  by  the  moving  forward  bodily  of  the 
second,  aided  by  the  third  molars,  the  development  of 
which  is  then  likely  to  be  perfect,  and  their  eruption 
complete.  If  irregularity  of  the  teeth  takes  place  after 
the  twelfth  year,  the  second  bicuspid  (sometimes  the  first), 
rather  than  the  first  permanent  molar  (unless  it  be  a  pulp- 
less  one),  ought  to  be  extracted.  Should  the  first  be 
62 


NOTES    ON   OPERATIVE    DENTISTRY. 


63 


extracted  after  the  eruption  of  the  second  permanent 
molars,  these  teeth  (especially  the  two  lower  ones)  may 
incline  or  tip  forward  (Fig.  15),  and  the  bicuspids  may 


Fig.  15. 


move  backward  in  many  cases,  thus  causing  imperfect 
occlusion.  In  cases  where  calcification  is  defective,  and 
where  solution  of  the  lime-salts  of  the  teeth  takes  place 
rapidly,  and  the  first  and  second  molars  are  still  in  posi- 
tion with  their  pulps  living,  it  is  advisable  to  extract  the 
third  molars,  even  though  there  are  no  ca\dties  in  them, 
that  decay  of  the  posterior  approximal  surfaces  of  the 
second  molars  may  be  prevented.  It  is  very  rarely 
ever  necessary  to  resort  to  extraction,  except  of  the  teeth 
just  named,  and  under  the  circumstances  indicated.     The 

Fig.  16.* 


natural  teeth  should  be  kept  in  place  till  they  are  lost 
either  by  accident  or  through  the  absorption  (or  because 
of  necrosis)  of  the  alveolar  process  and  the  gums. 

*  Fig.  16. — Universal  root  and  deciduous  tooth  forceps. 


54  NOTES    ON    OPERATIVE    DENTISTRY. 

About  tlie  time  of  the  eruption  of  the  first  permanent 
molars,  and  while  the  deciduous  are  being  displaced  by 
the  permanent  teeth  (and  for  years  after  the  eruption  of 
the  latter),  examinations  should  be  made  frequently,  not 
only  for  the  purpose  of  averting  irregularity  of  the  organs, 
but  for  ascertaining  whether  solution  of  enamel  has  com- 
menced upon  the  approximal  surfaces  of  any  of  the  teeth, 
or  in  the  fissures  of  the  bicuspids  and  molars. 

Since  the  method  to  be  adopted  or  followed  in  correct- 
ing irregularity  of  the  teeth  depends  very  much  upon  the 
character  of  the  case  in  hand,  the  judgment  of  the  opera- 
tor must  be  depended  upon  to  provide  the  ways  and  means 
to  accomplish  the  object  sought. 

j,j^j  jY  .^  Solution  of  the  lime-salts  of  the  ap- 

-X  proximal  surfaces  can  be  prevented  by 
occasionally  polishing  the  enamel,  and 
having  the  patient  pass  floss-silk  between 
the  teeth  daily.  This  will  not  require 
as  much  attention  on  the  part  of  the 
operator  and  patient  as  when  the  so- 
called  permanent  separations  have  been 
made. 
According  to  the  latest  and  best  investigations,  decay  of 
the  enamel  and  dentine  is  the  same  as  the  breaking  or 
taking  down  of  the  elements  of  any  of  the  other  tissues  of 
the  body.  It  is  the  solution  of  the  lime-salts  of  the  basis- 
substance  of  both  the  enamel  and  dentine,  by  an  acid  hold- 
ing a  greater  affinity  for  some  one  of  the  elements  of  these 
tissues  than  they  hold  for  one  another,  aided,  in  the  dentine^ 
by  the  inflammation  which  takes  place  in  the  fibers  of 
living  matter.  It  is  simply  return  of  the  elements  of  the 
tissues  to  their  primal  condition. 

*Pig.  17.— Instruments  for  making  examinations. 


NOTES    ON    OPERATIVE   DENTISTRY. 


55 


Dr.  Frank  Abbott,  of  New  York,  after  having  examined, 
microscopically,  many  decayed  teeth  from  the  mouths  of 
over  thirty  different  persons,  sums  up  the  results  of  his 
researches  as  follows : 

"  I.  In  enamel,  caries  in  its  earliest  stage  is  a  chemical 
process.  After  the  lime-salts  are  dissolved  out,  and  the 
basis-substance  is  liquefied,  the  protoplasm  reappears,  and 
breaks  apart  into  small,  irregularly-shaped,  so-called  med- 
ullary or  embryonal  bodies.     (See  Fig.  18). 

J^  Fio.  18. 


Section  of  enamel  magnified  about  1200  diameters  ;  E,  E,  unchanged  enamel,  partly  de- 
prived of  its  lime-salts;  P,  P,  zone  of  enamel  with  lime-salts  so  dissolved  out  as  to  be 
granular ;  C,  shallow  depression  filled  with  protoplasmic  bodies  ;  iV,  flat  epithelial  bodies, 
remnants  of  Nasmyth's  njembrane  ;  L,  L,  similar,  flat  epithelia. 

"  II.  Caries  of  dentine  consists  in  a  decalcification,  and 
in  turn  a  dissolution  of  the  glue-giving  basis-substance, 
around  the  canaliculi  as  well  as  between  them.  The 
living  matter  contained  in  the  canaliculi  is  transformed 
into  nucleated  protoplasmic  bodies,  which,  together  with 
protoplasmic  bodies  originating  from  the  living  matter  in 
the  basis-substance,  form  the  so-called  indifferent  or  in- 
flammatory tissue.     (See  Fig.  19). 


56 


NOTES    ON   OPERATIVE   DENTISTRY. 


"  ni.  Cement,  if  attacked  by  caries,  exhibits  first  all  the 
phenomena  known  to  be  present  in  the  early  stages  of  in- 
flammation of  bone.  The  protoplasmic  cement-corpuscles, 
as  well  as  the  basis-substance,  after  its  decalcification  and 
liquefaction,  produce  indifferent  or  inflammatory  elements. 

Fig.  19. 


Cross-section  of  dentine  magnified  1000  diameters  ;  a,  transTerse  section  of  the  den- 
tinal fiber  with  delicate  radiated  ofi'shootB  ;  l,  l>,  canaliculi  moderately  enlarged  ;  c,  c,  still 
further  enlarged  ;  d,  <l,  two  or  more  nuclei  surrounded  by  a  varying  amount  ol  iirotoplasm  ; 
e,  e,'.canaliculi  enlarged  to  ten  or  fifteen  times  their  original  diameter  and  filled  with  a 
partly  nucleated  protoplasm  ;  /,  longitudinal  cavities  arising  from  the  confluence  of  several 
cavities  in  one  main  direction  ;  y,  g,  large  spaces  Ijetween  which  only  scanty  traces  of  un- 
changed basis-Fubstance  are  left ;  h,  h,  basis-substance  entirely  disappeared,  in  the  place  of 
which  so-called  medullary  elements  remain. 

"IV.  The  indifferent  elements  originating  through 
the  carious  process  from  enamel,  dentine,  and  cement  do 
not  proceed  in  new  formation  of  living  matter,  but  become 


NOTES    ON   OPERATIVE    DENTISTRY.  57 

disintegrated  and  transformed  into  a  mass  crowded  with 
micrococci  and  leptothrix. 

"  V.  Caries  of  a  living  tooth,  therefore,  is  an  inflam- 
matory process,  which,  beginning  as  a  chemical  process, 
in  turn  reduces  the  tissues  of  the  tooth  into  embryonic  or 
medullary  elements,  evidently  the  same  as  during  the  de- 
velopment of  the  tooth  have  shared  in  its  formation ;  and 
its  development  and  intensity  are  in  direct  proportion  to 
the  amount  of  living  matter  which  they  contain,  as  com- 
pared with  other  tissues. 

"  VI.  The  medullary  elements,  owing  to  want  of  nutri- 
tion and  to  continuous  irritation,  become  necrosed,  and  the 
seat  of  a  lively  new  growth  of  organisms  common  to  all 
decomposing  organic  material. 

"  VII.  Micrococci  and  leptothrix  by  no  means  produce 
caries;  they  do  not  penetrate  the  cavities  in  the  basis- 
substance  of  the  tissues  of  the  tooth,  but  appear  only  as 
secondary  formations,  owing  to  the  decay  of  the  medullary 
elements. 

"  VIII.  In  pulpless  teeth  '  caries  is  a  chemical  process, 
assisted  only  by  the  decomposition  of  the  glue-giving 
basis-substance  of  dentine  and  cement.'  " 


Wlien  solution  of  the  enamel  has  commenced  at  or  near 
the  part  of  one  tooth  that  is  in  contact  with  another,  the 
teeth  should  be  separated  by  pressure,  so  that  needless  cut- 
ting of  tissue  may  be  avoided ;  the  rubber-dam  should  be 
applied,  and  the  superficial  decalcified  basis-substance  of 
the  enamel  removed  by  the  use  of  fine,  sharp  files,  and  nar- 
row strips  cut  from  emery-cloth  of  the  finer  grades,  such 
as  No.  J  and  ISTo.  0.  If,  after  the  removal  of  the  decalcified 
portion  from  the  periphery  of  the  enamel-columns  or 
rods,  the  whole  surface  presents  the  appearance  of  normal 


58  NOTES    ON   OPERATIVE    DENTISTRY. 

tissue,  this  surface  should  be  carefully  polished  with  pul- 
verized pumice,  applied  upon  linen  tape  or  a  soft-rubber 
disk.  K  there  remains  a  portion  of  enamel  of  a  lighter 
or  other  shade  than  that  which  surrounds  it,  all  that  part 
where  dissolution  had  taken  place  has  evidently  not  been 
removed,  and"  it  may  extend  to  the  dentine,  thus  necessi- 
tating the  cutting  out  of  all  the  lime-salts  where  solution 
of  tissue  has  occurred,  and  the  thorough  preparation  and 
careful  filling  of  the  cavity  presented. 

In  those  cases  especially  where  the  system  has  been 
maintained  in  good  condition  during  childhood  and  youth, 
and  the  tissues  are  first-class,  solution  takes  place  slowly, 
and  does  not  become  very  extensive,  so  that  where  only 
the  outer  layers  of  the  enamel-prisms  are  dissolved  away, 
this  portion  can  be  removed,  and,  after  a  finely-finished 
surface  is  made,  decay  will  not  be  likely  to  commence 
again. 

In  no  case  should  a  permanent  separation  be  made 
between  the  teeth,  however,  for,  even  in  such  cases  as 
those  just  mentioned,  food  may  so  wedge  against  the 
gum  as  to  bring  about  its  recession,  and  the  exposure  of 
the  necks  of  the  teeth,  and  finally  lead  to  the  formation 
of  a  cavity  at  these  parts. 

Moreover,  separations  should  not  be  made,  for  the 
reasons  that  they  interfere  with  mastication,  annoy  the 
patient,  and,  with  few  exceptions,  solution  of  the  lime- 
salts  of  the  parts  that  have  been  cut  is  not  prevented.  The 
teeth  separated  again  come  in  contact  almost  invariably, 
except  where  they  arc  prevented  by  antagonizing  teeth ; 
food,  wedging  between  them,  undergoes  fermentation,  and 
solution  of  the  enamel  and  dentine  takes  place,  and  that, 
too,  in  a  part  of  the  tooth  where  it  is  difiicult  to  perform 
a  first-class  operation.     This  may  not  occur,  however,  till 


NOTES   ON    OPERATIVE    DENTISTRY.  59 

long-continued  pressure  of  food  paralyzes  the  nerves  in  the 
papillae  of  the  gum-tissue  pressed  upon,  and  breaks  the  nu- 
trient circuit,  or  obstructs  the  movement  of  the  molecules 
of  living  matter  through  that  fine  reticulated  line  between 
the  gum  and  the  brain,  and  the  patient  is  no  longer  notified 
of  the  presence  of  such  obstruction  to  the  neural  and 
vascular  circulation.  This  condition  of  the  gum-tissue  as 
inevitably  leads  to  the  return  of  the  elements  to  their 
embryonal  state,  as  does  interference  with  the  nutrition  of 
any  other  part  of  the  system. 


APPLICATION  OF  THE  RUBBER  DAM. 


rr^HAT  operations  may  be  properly  performed,  and  that 
-"-  gold  or  any  other  filling-material  may  be  inserted 
in  cavities  as  well  as  possible,  it  is  necessary  that  the  parts 
be  kept  dry  by  the  use  of  the  rubber  dam.  Even  the 
vapor  contained  in  the  exhalations  from  the  lungs,  as  well 
as  the  touch  of  a  finger,  prevents  the  cohesion  of  gold, 
which  cohesion  is  essential  to  success  in  the  insertion  of 
all,  and  particularly  in  the  making  of  really  fine,  fillings. 
It  is  not  only  absolutely  necessary  for  the  pieces  of  foil  to 
cohere  in  all  those  cases  where  the  gold  must  be  made 
solid  and  strength  must  be  gained  for  the  protection  and 
support  of  enamel  (frail  walls  of  which  must  be  incased, 
as  it  were,  in  gold),  but  when  fillings  are  inserted  in  the 
masticating  surfaces  of  the  teeth  it  is  also  necessary  that 
cohesion  of  the  particles  of  foil  be  unimpaired,  to  prevent 
the  scaling-ofi"  of  the  gold  as  the  cusps  wear  away  and  the 
dentine  becomes  exposed  from  attrition. 

The  rubber  dam  (for  which  we  are  indebted  to  Dr.  S.  C. 
Barnum)  ought  to  be  applied  in  every  case,  and  it  can  be 
used  in  all  cases  so  as  to  exclude  moisture,  provided  the 
operator  has  the  ability  to  apply  it  successfully. 

In  addition  to  having  the  rubber  dam  applied,  and  par- 
ticularly when  operating  upon  the  lower  teeth,  it  is  best  to 
take  the  saliva  from  the  mouth  by  means  of  Fisk's  saliva 
ejector,  if  running  water  be  at  hand ;  if  not,  then  a  com- 
mon saliva  ejector  may  be  u§ed.  This  may  be  manipu- 
60 


NOTES    ON    OPERATIVE    DENTISTRY.  61 

lated  either  by  the  patient  or  by  an  assistant  of  the  operator. 
The  light-medium  rubber  is  the  best  for  general  use.  It 
should  be  cut  into  pieces  about  nine  inches  long  and 
seven  and  one-half  or  eight  inches  wide.  Each  piece 
ought  to  be  kept  for  the  patient  for  whom  it  was  first 
used ;  a  convenient  way  of  keeping  it,  and  the  name  of  the 
patient  with  it,  is  to  have  a  blank-book  made  of  dense 
blotting-paper. 

The  application  of  the  rubber  dam  and  the  clamp,  as 
well  as  the  removal  of  decay  and  nearly  the  whole  of  the 
preparation  of  a  cavity  for  filling,  gives  the  patient  pain^ 
but  the  operator  ought  always  to  feel  that  he  has  living 
tissue  to  operate  upon,  and  while  performing  each  opera- 
tion thoroughly,  he  can  and  should  be  kind  and  sympa- 
thetic, and  handle  his  patient  gently.  Although  pressing 
away  the  gum  is  necessary,  in  order  that  the  rubber  dam 
may  be  carried  to  the  neck  of  the  tooth  to  be  operated 
upon  and  be  tied  to  each  tooth  adjoining,  yet,  when 
properly  applied,  with  carefully  fitted  clamps  and  ligatures 
of  waxed  floss-silk,  inflammation  of  the  tissue  does  not 
take  place,  except,  perhaps,  in  rare  instances,  and  in  these 
it  soon  subsides. 

Patients  usually  endure  operations  just  in  accordance 
with  the  way  they  are  handled  by  the  operator,  and  he 
must  first  gain  the  confidence  of  his  patient  by  being  con- 
scientious and  sincere,  and  by  showing  that  he  knows 
exactly  what  he  is  about,  and  doing  nothing  but  what  he 
would  have  done  for  himself.  Very  little,  if  any,  more 
pain  need  be  inflicted  during  the  proper  preparation 
of  a  cavity  for  the  insertion  of  one  material  than  for 
another,  and  it  need  not  often  be  necessary  to  keep 
i.  patient  in  the  chair  over  two  hours ;  yet  patients  some- 
times suffer  far  more  pain  and  fatigue  in  one  hour  having 


62  NOTES    ON    OPERATIVE    DENTISTRY. 

an  ordinary  and,  perhaps,  almost  worthless  filling  inserted 
by  unskilled  and  careless  hands,  than  during  the  perform- 
ance of  an  extensive,  difficult,  and  fine  operation  taking 

Fig.  20.* 


'Il!l!ili!lll!lll!l!ii; 


e 


n 


-/^ 


^ 


^ 

%  ^ 

•\vy — 


the  skilled  and  careful  operator  three,  four,  or  even  five 
hours  to  complete. 

*rig.  20  represents  several  sets  of  holes  in  a  piece  of  rubber  dam, 
showing  how  each  set  ought  to  be  located  for  the  teeth  as  they  are  to  be 
operated  upon,  the  sets  of  holes  to  be  cut  as  needed  at  different  times, 
and  some  of  them  made  in  different  portions  of  the  same  (or  in  other 
pieces  of)  rubber  dam.  i 

All  the  holes  ought  to  be  made  within  the  Upper  (or  lower)  half  of  the 
rubber  dam  (the  center  Ijcing  shown  by  the  dotted  line)  and  at  the  same 
aisianCa — a;  full  inch — from  the  upper  margin  of  the  rubber  as  shown 


NOTES    ON    OPERATIVE    DENTISTRY.  63 

After  selecting  the  proper  place  in  the  rubber  dam  for 
naaking  the  holes  for  the  teeth  to  which  it  is  to  be  applied 
in  the  case  in  hand,  it  should  be  carefully  folded  at  that 
part  and  cut  with  scissors,  or  the  holes  can  be  made  with 
a  punch.  The  holes  should  be  fully  a  line  in  diameter 
for  the  molars,  or  almost  a  line  and  one-half  in  diameter 
when  the  rubber  is  to  be  stretched  over  a  clamp,  and 
from  half  a  line  to  the  sixteenth  of  an  inch  for  the  other 
teeth  (Fig.  20).  The  width  of  the  rubber  dam  between 
the  holes  should  be  about  an  eighth  of  an  inch,  or  should 
correspond  to  the  space  at  the  necks  of  the  teeth  to  which 
it  is  to  be  applied.  "With  the  exception  of  the  holes  for 
the  upper  incisors  (Fig.  20,  a)  and  those  for  the  upper 
cuspids  and  bicuspids,  no  hole  ought  to  be  cut  within 
about  three  inches  of  the  edge,  for  the  reason  that  less 
margin  of  rubber  than  this  cannot  be  nicely  folded  and 
held  away  from  the  teeth  to  which  it  is  attached. 

R  U  B  B  E  R  -  D  A  M     C  L  A  M  P  S. 

Various  forms  and  sizes  of  clamps  are  made  for  the 
rubber  dam,  the  most  complete,  satisfactory,  and  useful  of 


above  the  holes,  a,  and  they  should  be  arranged  in  the  manner  illustrated, 
on  each  side  of  the  center  indicated  by  the  perpendicular  dotted  line. 

Location  of  Holes  for  Teeth  in  different  Parts  of  the 
Mouth. — o,  holes  for  the  upper  central  and  lateral  incisors  ;  6,  for 
the  upper  bicuspids  and  first  molar,  left  side ;  c,  for  the  upper  bicus- 
pids and  first  and  second  molars,  right  side, — one  hole  additional  to  be 
made  just  back  of  these,  if  the  clamp  and  rubber  are  to  be  applied  to  the 
third  molar ;  d,  position  of  the  holes  for  the  lower  incisors  ;  e,  for  the 
lower  bicuspids  and  first  molar,  right  side  ;  /,  lower  left  bicuspids  and 
first  and  second  molars  ; — the  -|-  indicates  the  position  for  holes  for  the 
other  teeth. 

While  the  holes  in  their  general  arrangement  are  shown  full  size,  the 
rubber  cannot  be  illustrated  as  large  as  it  ought  to  be.  It  should  be 
seven  and  one-half  or  eight  inches  wide  (counting  from  the  line  above 
the  holes,  a)  and  nine  inches  long, — four  and  one-half  inches  each  way 
from  the  perpendicular  dotted  line.  The  holes  for  the  second  upper 
bicuspids  are  too  large  in  the  cut. 


64 


NOTES    ON    OPERATIVE   DENTISTRY. 


which,  and  those  causing  the  patient  the  least  pain,  are  the 
set  of  thirty-two  (a  special  clamp  for  each  separate  tooth) 
devised  by  Dr.  Delos  Palmer,  of  Xew  York.  Those  in- 
tended for  the  molars  are  here  illustrated  (Fig.  21). 

The  clamps  should  be  put  in  place  with  suitable  forceps. 
The  one  selected  for  the  tooth  to  be  operated  upon  ought 
to  be  placed  in  position  first,  in  almost  every  case  (especially 


K.  S.,  6. 


Fig.  21  * 

Superior. 

K.  S.,  7. 


K.  S.,  8. 


R.  I..  6. 


Inferior. 
R.  I.,  7. 


R.  I., 


L.  I.,  7. 


L.  I. 


on  the  molars),  and  the  rubber  dam  then  stretched  over 
the  clamp  and  the  tooth  to  which  it  is  fixed,  and  at  once 
applied  to  the  one  adjoining  or  to  the  two  teeth  anterior 

*A  special  clamp,  designed  by  Dr.  Delos  Palmer,  for  each  separate 
molar  is  here  shown  (Fig.  21).  The  letters  and  numbers  signify  that 
R.  S.,  0,  for  instance,  is  intended  for  the  right  superior  sixth  tooth  (first 


NOTES    ON    OPERATIVE   DENTISTRY.  65 

to  it.  The  chiiup  iuxented  by  Dr.  H.  ('.  LongiuM^kur,  of 
Philadelphia,  is  a  good  form  for  general  use  (Fig.  22);  be- 
cause of  the  recurvature  of  the  flanges,  it  does  not  bear  upon 
the  festoons  of  the  gums  so  as  to  injure  them.  As  the  rubber 
is  stretched  over  each  crown,  the  ^^^^_  .,2* 

floss-silk  must  be  passed  between 
the  teeth  to  carry  down  the  part 
that  separates  the  hole  for  one  tooth 
from  the  one  for  tlie  other.  In 
most  cases  the  rubber  should  be 

carefully  tied  to  each  tooth  to  Avhich  it  is  applied.  Where 
there  is  danger  of  cutting  or  tearing  the  rubber  dam  and 
floss-silk,  while  placing  them  between  the  teeth,  the  sharp, 
irregular  edges  of  enamel  surrounding  the  cavity  within 
the  approximal  wall  of  either  tooth  ought  to  be  removed 
with  a  fine  ribbon-sa\\'  passed  from  the  masticating  surface 
to  the  neck  of  the  tooth.  Clamps  need  be  applied  in  but 
few  cases  other  than  to  the  molars. 

The  rubber  dam  ought  to  be  applied  to  a  sufficient 
number  of  teeth  to  make  the  tooth  to  be  operated  upon 
accessible,  although  it  is  scarcely  necessary  to  apply  it 
to  but  three  or  (rarely  more  than)  four  teeth,  even 
when  ca\Hties  within  the  approximal  walls  are  to  he  pre- 
pared and  tilled. 


molar),  counting  back  from  the  median  line.  The  universal  screw- 
clamp,  devised  by  Dr.  E.  Parmly  Brown,  is  an  excellent  appliance,  also, 
and  many  more  of  the  clamps  and  other  appliances  which  have  been  made 
should  be  mentioned,  as  well  as  many  articles  that  have  been  written  from 
time  to  time  relating  directly  or  indirectly  to  a  number  of  the  points  in 
operative  dentistry  herein  considered,  but  it  would  be  too  much  of  a  task 
to  refer  to  the  merit  of  each  and  to  name  the  credit  due  the  inventoi-s  and 
writers. 

*  There  are  several  sizes  of  these  clamps.  Those  with  the  straight  hoop.- 
are  often  unavailable  for  the  tooth  to  be  operated  on,  but  they  serve 
well  when  placed  on  the  one  back  of  it  ti>  keep  the  rubber  dam  out  of  the 
way. 

5 


6() 


XOTES    OX    OPERATIVE, DENTISTRY. 


The  edges  of  the  rubber  ought  to  be  carefully  folded  or 
nicely  placed  back  upon  the  side  of  the  face,  and  held  out 
of  the  way  by  a  rubber-dam  holder  (Fig.  23),  and  for  the 


Fig.  23. 


comfort  of  the  patient,  a  fine,  soft  napkin  should  be  put 
under  the  rubber  next  to  the  lips,  chin,  and  checks. 


I'REPARATION  OF  FILLINGMATERIALS. 


(i  0  L  D     F  0  1  L. 

nrX  the  [(reparation  of  gold  for  the  various  operations 
-L  required,  a  half-leaf  of  light  gold  foil  for  small  (or 
the  smallest),  a  whole  leaf  for  medium,  and  two  leaves  for 
large  fillings,  should  l)e  taken  from  the  book  by  means  of 
a  spatula  or  the  foil-carrier,  and  placed  upon  a  piece  of 
spunk  covered  with  white  kid.  The  foil  should  then  be 
smoothly  folded  with  an  ivory  or  nickel-plated  spatula 
(Fig.  24)  into  a  tape-like  form  of  about  seven,  nine,  or 


Fig.  2i. 


eleven  lines  in  width  (Fig.  25,  a,  6,  and  c,  thus  making 
Xos.  12,  20,  and  32 — if  the  foil  be  Xo.  4)  respectively;  then 
taken  up  with  the  foil-carrier  and  cut  across  into  pieces 
about  a  line  wide  {d).  For  some  cases,  such  as  the  filling 
of  pulp-chambers,  the  pieces  of  foil  ought  to  be  less  than 
a  line  wide  (t). 

As  these  pieces  are  cut  from  the  ribbon  they  should  fall 
upon  the  kid  covering  the  spunk,  or  upon  very  tine  linen 
napkins.  Each  of  the  pieces  of  foil  can  afterward  be  readily 
taken  up  A\ith  light-pointed  foil-carriers  (Fig.  26),  or  the 
[tacking-instrument,  and  passed  over  the  flame  of  alcohol 
till  the  piece  has  a  rose-tinted  shade  or  is  made  cohesive, 
when  it  must  be  put  in  place  at  once  and  solidified. 

Heavy  foil,  such  as  Xos.  30,  40,  and  60,  cut  into  the  same 

67 


68 


NOTES    ON    OPERATIVE    DENTISTRY. 


sized  pieces  as  folded  foil  (Fig.  25,  (/),  can  be  used  to  ad- 
vantage ill  most  cases,  especially  in  extensive  restoration 
of  contour  of  missing  tissue,  although  light  foil,  when 
prepared  as  just  described,  can  be  more  easily  inserted  in 
small  cavities,  fissures,  and  grooves. 

Fi(i.  25. 


When  prepared  in  the  manner  described,  each  piece  of 
foil  can  be  readily  introduced,  folded  over  and  again 
upon  itself,  and  each  fold  separately  solidified.  Tlic  opera- 
tor can  be  certain  of  these  convenient  narrow  pieces 
remaining  firmly  anchored  in  the  starting-point,  and  each 
additional  piece  readily  adheres  to  and  is  easily  made 
compact  with  that  already  in  position,  thus  making  the 
whole  filling  uniroi-iii  in  density.     Kach  [)iece  of  foil  sliould 


NOTES    ON    OPKUATIVK    DKNTISTKV. 


Gl) 


remain  in  the  position  in  wliicli  it  ii^  placed,  and  tlie  forms 
of  the  pieces,  when  prepared  as  described,  will  be  such 
that  they  can  be  inserted  in  all  classes  of  cavities  conven- 
itntlv  and  with  certainty. 

The  abuse  and  not  the  use  of  cohesive  gold    Fig.  20. 
has  led  to  its  condemnation,  and  they  alone  con- 
demn it  who  have  not  prepared  and  manii)U- 
lated  it  properly  and  successfully. 

Foil  should  always  be  prepared  in  the  manner 
stated  and  be  used  in  the  form  illustrated,  and 
all  gold  ought  to  be  cohesive,  particularly  when 
a  mallet  is  used,  so  that  the  particles  or  pieces 
may  surely  and  permanently  remain  together. 
There  is  no  other  method  by  which  gold  can 
be  made  so  solid  and  so  uniform  in  density, 
with  such  ease,  certainty,  and  rapidity,  as  with 
the  electro-magnetic  mallet,  but  it  ought  always 
to  be  well  adjusted,  the  battery  should  be  prop- 
erly attended  to,  and  the  apparatus  must  l»e 
operated  understandingly. 


TIN. 

For  the  tilling  of  narrow  tissures  and  small 
sulci  of  the  bicuspids  and  molars,  tin  is  next  to 
gold  in  value  as  a  filling-material,  and  when  put 
solidly  in  place  in  such  cavities  attrition  does 
not  wear  away  the  material  so  deeply  as  to  im- 
pair the  operation.  The  rubber  dam  should  be 
applied,  the  cavity  prepared,  and  the  foil  folded, 
out  (with  the  foil  shears.  Fig.  27),  and  made 
compact  with  the  mallet,  as  carefully  when 
tin  is  inserted  as  if  gold  were  used.  More  time  is 
usually    required,    however,    to    properly    fill    a    cavity 


70  NOTES    ON    OPERATIVE    DENTISTRY. 

with  tin  foil  than  with  o'old,  when  the  electro-maa'iietic 
mallet  is  used,  mainly  for  the  reason  that  in  tin  there  is 
not  that  cohesive  property  to  keep  each  piece  in  place 
with  certainty  while  the  material  is  being  solidified ;  there- 
fore, since  time  rather  than  material  is  valuable  to  all  those 

Fig.  27. 


liaving  a  full  practice,  it  is  better  for  both  patient  and 
operator  to  make  use  of  gold  rather  than  tin  as  a  permanent 
filling-material. 


A  M  A  L  (I  A  M. 


If,  in  performing  an  operation  which  is  to  be  a  perma- 
nent one,  the  operator  cannot  so  manipulate  gold,  in  any 
given  case,  as  to  make  the  filling  moisture-tight,  and  yet 
decides  not  to  use  tin,  but  to  insert  amalgam  instead ;  or 
generally,  if  an  amalgam  is  to  be  used  at  all  by  those  who 
restore  completely  the  contour  of  missing  tissue  and 
make  the  margins  free  from  contact,  they  certainly  need 
"  contouring  amalgam,"  which  is  said  to  be  the  best  (or 
the  "  standard  ")  of  such  materials.  This  amalgam  is 
composed  of  about  58  parts  of  silver,  87  of  tin,  and  5  of 
gold,  and  it  is  claimed  to  be  (juick-setting,  and  to  have 
good  edge-strength  and  "  good  color,"' — that  is,  a  better 
color  than  most  other  alloys. 

The  amalgam  mass,  when  ready  for  insertion,  should  be 
a  little  plastic — sufiiciently  so  not  to  crumble,  but  to  pack 
nicely,  piece  by  piece,  with  very  light  malleting.  The  same 
care  should  be  taken  in  filling  with  amalgam  as  with  any 
other  material.     It  is  best,  especially  in  large  cavities  and 


NOTES    ON    OPERATIVE    DENTISTRY.  71 

in  filling  the  deciduous  teeth,  to  first  fill  the  cavity  (after 
applying  the  rul)l)er  dam)  so  far  as  to  entirely  co\'er  the 
dentine  with  oxychloride  of  zinc,  and  secure  anchorage 
in  the  cement,  or  to  so  use  the  amalgam  that  it  may  come 
in  direct  contact  with  the  enamel  only;  thus,  to  a  great 
extent,  avoiding  discoloration  of  the  tissue. 


THE  MALLET. 


"T^KFU RE  entering  into  a  description  of  operations,  it 
-*— "^     seems  Avell  to  consider  the  mallet  and  its  uses. 

During  the  year  1860  Dr.  W.  IT.  Atkinson  introduced 
tlie  mallet  for  making  each  piece  of  gold  compact  as  it  is 
placed  in  the  cavity,  he  having  received  the  idea  of  using 
a  liand-mallet  from  Dr.  E.  Merit,  of  Pittsburgh,  Pa.,  who 
had  used  such  an  instrument  for  condensing  gold  (en  ittassc) 
after  it  all  had  been  put  in  the  cavity. 

That  an  assistant  or  malleter  might  be  dispensed  with, 
various  forms  of  automatic  and  "  engine  "  mallets  were 
afterwards  invented,  manufactured,  and  used  with  varied 
success,  but  the  finest  and  best  instrument  now  made  and 
in  use,  when  j)roperly  understood  and  skillfally  operated, 
is  the  electro-magnetic  mallet. 

That  operators  may  the  better  understand  and  operate 
the  electro-magnetic  mallet,  a  full  description  of  the  con- 
struction, adjustment,  and  movement  of  its  parts,  and 
management  of  the  battery,  is  here  given. 

THE    E  L  E  <'  T  R  0  -  :\I  A  ( i  N  ]•:  T  T  (_'    M  A  L  L  E  T, 

Electricity  is  manifested  as  atmospheric,  statical  or 
frictional,  voltaic  or  galvanic,  dynamic,  and  magnetic. 
Magnetic  electricity  consists  in  the  spiral  circulation  of 
electricity  through  a  wire  around  a  bar  of  soft  iron, 
making  the  metal  temporarily  magnetic. 

Dr.  W.  G.  A.  Bonwil]  first  conceived  the  idea  of  the 
72 


NOTES    ON    OPERATIVE    DENTISTRY.  73 

<*lectro-niagnetic  mallet,  February  27, 1867,  while  his  atten- 
tion was  called  to  the  electric  telegraph  by  the  more  than 
ordinarily  distinct  tapping  of  the  "  sounder  "  in  a  tele- 
graph office  at  the  Continental  Hotel,  Philadelphia, — 
within  a  square  of  the  spot  where  Franklin  succeeded  in 
his  exjieriment  of  collecting  electricity  from  the  clouds. 

In  the  construction  of  the  electro-magnetic  mallet  Dr. 
Bonwill  gained  some  ideas  from  the  electric  telegraph 
instrument,  the  sound  of  which  had  indicated  to  him  that 
some  such  taps,  if  given  with  greater  force,  might  have 
sufficient  impact  to  solidifv  gold.  There  was  nothing  new 
in  the  arrangement  of  a  coil  of  wire  around  a  bar  of  soft 
iron,  which  bar,  upon  the  passage  of  a  current  of  electric- 
ity through  the  coil,  becomes  a  magnet  and  attracts  to  it 
one  end  oF  an  armature  moving  upon  a  pivot  at  its  center ; 
for  in  1832  Prof.  Morse  was  experimenting  in  this  direc- 
tion, and  the  device  can  now  be  seen  in  every  telegraph 
instrument.  Dr.  J'age  did  not  make  any  claim  of  origi- 
nality for  a  similar  device  used  in  1836  in  his  experiments 
in  reference  to  magneto-electrical  apparatus  for  "  admin- 
istering electricity  as  a  remedial  agent :''  but  in  order  that, 
when  the  encoiled  bar  is  demagnetized  by  the  breaking  of 
the  current  on  the  wire  surrounding  it,  the  armature  thus 
released  should  not  travel  beyond  reach  of  the  attraction 
of  the  bar  w^hen  the  circuit  is  again  closed  and  the  bar 
again  becomes  a  magnet,  he  added  a  small  thumb-screw, 
against  which  when  set  free  the  armature  recoiled  and 
stopped.  This  Dr.  Page  claimed  as  a  valuable  improve- 
ment only  in  connection  with  an  electro-magnet.  Dr. 
Bonwill  modified  and  improved  the  electro-magnet  and- the 
armature,  and  so  arranged  two  magnets  and  an  armature 
as  to  make  the  electro-magnetic  mallet, — inventing  and  con- 
structing such  parts  as  were  necessary  to  complete  it.    The 


74  XOTES    ON    OPERATIVE    DENTISTRY. 

name  of  Dr.  V^.  G.  A.  Bouwill  will,  therefore,  be  con- 
nected with,  and  he  as  inseparable  from,  the  electro-mag- 
netic mallet  as  that  of  Prof.  S.  F.  B.  Morse  and  the  electro- 
magnetic telegraph.  As  with  the  telegraph,  so  with  the 
electro-magnetic  mallet,  moditications  and  improvements 
have  been  made  by  others  as  well  as  l»y  its  originator,  but 
such  of  these  changes  as  add  value  to  the  fine  and  wonder- 
ful piece  of  mechanism  but  increase  rather  than  cancel 
the  debt  of  gratitude  we  all  owe  its  inventor. 

Although  Dr.  Bonwill  has  since  invented  an  instrument 
which  he  calls  a  "  mechanical  mallet,"  similar  in  appear- 
ance to  the  hand-piece  of  the  dental  engine,  and  operated 
like  it  with  the  foot;  yet  in  a  letter  received  from 
him,  he  states  that  he  is  "not  unmindful  of  the  part" 
the  writer  has  played  •'  in  assisting  to  give  the  electro- 
magnetic mallet  a  glory  second  to  no  other  invention  ever 
given  to  dentistry."  The  real  glory  of  the  electro-mag- 
netic mallet  consists  in  the  good  it  has  done  those  who 
have  used  it  successfully.  Of  such  assistance  has  it  been 
to  the  Avriter  since  the  spring  of  1878  that  he  feels  it  has 
already  done  much  towards  prolonging  his  life.* 

The  manner  of,  or  one  position  of  the  hand  in,  holding 
the  electro-magnetic  mallet  is  here  illustrated  (Fig.  28),  the 
thumb  and  index  finger  serving  to  steady  and  guide  the 
instrument  the  same  as  a  pen  or  pencil,  and  to  close  and 
open  the  circuit. 

The  electro-magnetic  mallet  here  shown,  and  as  now- 
made,  consists  of  a  pair  of  magnets  :  an  armature,  and  a 
device  for  regulating  the  length  of  the  stroke  of  the  same ; 
a  hard-rubber  hand-piece  in  which  the  packing  instrument 

*  That  the  electro-magnetic  mallet  be  made  to  work  well,  aid  in  maldiig 
fine  filling!?,  and  benefit  the  operator,  has  ever  boon  the  sincere  wish  and 
strong  desire  of  the  author. 


NOTES    ON    OPERATIVE    DENTISTRY. 


is  placed  and  operated,  the  same  resting  against  a  hard- 
rubber  piece  called  a  plunger,  which  is  so  adjusted  by  a 
screw  as  to  have  the  end  of  the  armature  or  the  mallet- 
head  drive  the  packing  instrument  only  to  a  certain  extent  ; 
then  there  is  a  very  important  part  called  the  interrupter, 
or  autonvatic  circuit-breaker.  There  are  other  important 
parts  which  will  be  preferred  to  further  on. 

Fig.  2s. 


The  cores  ol  the  magnets  are  made  of  the  best  soft  iron. 
They  are  placed  side  by  side,  about  one-C|uarter  inch  apart. 
At  one  end  they  are  connected  with  each  other  by  screws 
through  an  end-plate — a  piece  of  soft  iron  about  a  halt- 
inch  long,  and  of  the  same  width  and  thickness  as  the 
cores.  Each  core  is  made  about  one  and  a  quarter  inches 
long,  three-quarters  of  an  inch  wide,  and  an  eighth  of  an 
inch  thick  through  the  center  along  its  whole  length,  and 
the  iron  is  rounded  down  a  little  to  the  edges  so  as  to 
make  both  sides  slightly  convex.     The  insulated  copper 


76  NOTES    ON    OPERATIVE    DENTISTRY. 

wire  can  then  be  more  closely  placed  around  the  iron,  thus 
insuring  more  complete  "  saturation  of  the  core."  A 
small  flange  should  be  left  at  the  end  of  each  core  over 
which  the  armature  is  to  rest,  that  the  rubber  end-piece 
may  be  held  in  place  while  the  wire  is  being  (and  after  it 
has  been)  wound  around  the  iron.  The  soft  iron  end-plate 
which  is  screwed  to  and  which  connects  the  cores  keeps 
tlie  hard-rubber  at  that  end  in  place. 

When  the  sott  iron  cores,  end-plate,  and  armature  are 
properly  formed  and  smoothly  finished,  they  must  be 
annealed, — heated  to  redness  and  placed  in  hot  finely- 
granulated  charcoal  to  cool  gradually.  All  other  metallic 
parts,  except  a  few  screws  and  the  springs  at  the  end  of  the 
rubber  hand-piece,  are  made  of  brass. 

After  the  hard-rubber  end-pieces  are  accurately  fitted  to 
and  placed  upon  the  cores,  the  soft  iron  end-plate  must  be 
screwed  to  each  core  separately  while  the  copper  wire  is 
being  wound  around  the  same.  When  five  layers  are 
wound  upon  one  core  the  end-plate  should  be  detached 
from  it  and  placed  upon  the  other  core  to  keep  the  rubber 
piece  at  the  end  of  it  in  place  while  the  wire  is  being 
wound  around  the  iron. 

Previous  to  placing  the  end-pieces  upon  the  core,  its 
sides  ought  to  be  entirely  covered  with  the  finest  silk  court- 
plaster,  that  the  wire  may  be  the  better  insulated  from  the 
iron.  Chopper  wire  Xo.  23  (American  gauge),  insulated 
with  silk,  should  be  very  carefully  and  closely  wrapped 
around  the  core,  and  after  one  layer  is  on,  this  and  each 
succeeding  layer  had  best  be  covered  with  one  thickness  of 
Japanese  bibulous  paper,  which  should  be  simply  saturated 
with  a  solution  of  gum-shellac  in  alcohol ;  this  makes  the 
insulation  more  complete.  After  five  layers  of  wire  are 
thus  placed  upon  each  core,  the  magnets  should  be  put 


NOTES    ON    OPERATIVE    DENTISTRY. 


77 


together,  the  iron  end-plate  screwed  to  both  cores,  and  one 
Fig.  29.  end  of  the  wire  from  one 

magnet  twisted  with  one 
from   the    other.     One  of 
the  loose  ends  is  thereafter 
to  he  connected  with  the 
hiterrupter,  and  the  other 
end  fastened  to  one  of  the 
posts   o^'er   which    one  of^ 
the  tubes  of  the  connect- 
ing  cord   which  connects 
the  mallet  with  the  battery 
is  to  be  placed.    It  has  been 
said   that   "  the  thickness 
of  the  helical  coil  must  be 
equal   to  the  diameter  of 
the  core,'"  and  five  layers 
of  No.  2;>  wire  make  up 
this  thickness — six  layers  more  than  do  it 
— when  the  diameter  of  the  core  is  one- 
eighth  of  an  inch.    The  mechanism  of  the 
other  parts  of  the  electro-magnetic  mallet 
can  be  understood  by  reference  to  and  by 
a  study  of  the  instrument  as  illustrated  in 
Fig,  29,  and  particularly  by  paying  close 
attention  to  the  description  of  the  various- 
parts  and  gaining  a  knowledge  of  their 
adjustment  and  movements,-^ 


*The   modifications    and    improvements    which    I 
inado  in  the  electro-magnetic  mallet,  briefly  stated., 
are  mainly  as  follows  :  In  1874  I  put  on  the  shaft  or 
rod  J,  to  serve  a  better  purpose  than  the  device  pre- 
viously used  to  fix  the  stroke  of  the  ai-mature,  and  to  make  its  movement 


78  NOTES  ON  OPERATIVE  DENTISTRY. 

The  connection  of  the  mallet  with  the  battery  is  made 
by  means  of  small  metallic  tubes  attached  to  the  two  sets 
of  wires  of  the  conducting  cord,  each  tube  fitting  tightly 
over  a  projecting  wire  or  post.  The  index  finger  is  placed 
through  the  ring  attached  to  the  hand-piece ;  the  end  of 
the  finger  resting  upon  the  flange  of  the  slide,  which, 
when  pressed  downward  towards  the  end  of  the  packing- 
instrument,  brings  the  positive  and  negative  poles  of  the 
battery  in  contact  under  the  slide  at  fS.  The  circuit  being 
thus  closed,  there  instantly  follows  an  influx  of  the  elec- 
trical current  through  the  helices,  when  the  armature  A, 
acting  as  a  mallet,  is  attracted  to  the  electro-magnets  B, 
and,  at  the  same  instant,  it  strikes  upon  the  hard-rubber 
plunger  C,  which  is  so  adjusted  as  to  have  sutficient  move- 
ment to  impart  a  blow  to  the  packing  instrument  JD,  the 
end  of  the  handle  of  which  is  placed  against  it.  The 
plunger  is  adjusted  and  kept  in  place  by  means  of  the 
screw  E.  A  spiral  spring  fits  loosely  around  the  plunger, 
and,  after  each  blow  is  struck,  immediately  carries  it 
towards  the  armature  to  again  receive  and  impart  the 
blow  given  by  the  armature  to  the  packing  instrument. 

steady,  or  preveut  the  o.scilhition  which  attended  the  operation  of  the 
instrument  when  only  the  rod  to  whieh  the  armature  is  attaciied  supported 
it.  I  attaciied  the  conducting  cord  ditt'erently,  and  made  thfe  wires  come 
in  closer  contact  with  the  mallet  through  small  tubes  (on  the  reverse  side 
of  the  instrument  as  here  illustrated,  but  seen  in  cut  No.  28).  Prin- 
cipally by  lessoning  the  number  of  layers  and  tlie  size  (using  No.  '2S,  in- 
stead of  No.  22,  American  gaugej  of  wire  upon  the  cores 'of  the  magnets,  I 
made  these  and  other  parts  of  the  mallet  much  smaller  than  the  Bonwill 
•'Improved"  instrument,  which  I  was  using  when  1  made  these  last 
rhanges,  in  187-j.  I  made  the  soft  iron  cores  a  little  convex  on  both  sides,  so 
that  the  insulated  copper  wire  could  be  the  more  certainly  and  perfectly 
wrapped  around  them,  and  thus  insure  more  complete  "saturation"  of 
the  iron.  I  made  no  special  change  in  the  armature,  e.vcept  to  make  it 
lightei-,  improve  it-  appearance  and  change  tlie  manner  of  hinging  it  to 


NOTES    UN    Ul'KKATIVK    DKNTISTllV.  79 

The  instant  the  armuture  is  attracted  to  the  magnets,  it 
also  strikes  upon  the  hard-rubber  point  F  on  the  rod  of 
the  interrupter,  and  thus  breaks  the  circuit  at  the  phiti- 
nuni  points  at  (I,  When  the  armature  is  carried  away 
from  the  magnets  bv  the  s[)ring  H,  and  is  caught  at  I, 
the  rod  of  the  interrupter  is  carried  back  to  its  position 
by  the  si>iral  spring  surrounding  it,  and  tlie  circuit  is 
again  closed.  The  instrument  is  thus  kept  in  operation 
as  long  as  slight  pressure  is  made  upon  the  slide  by  the 
index  finger. 

The  ends  of  the  soft  iron  cores  should  be  a  little  below 
the  surface  of  the  hard-rubber  plates — the  rubber  extend- 
ing about  the  thickness  of  tine  card-board  bej'ond  the  ends 
of  the  cores,  so  as  to  pre\'ent  actual  contact  of  the  arma- 
ture with  them.  When  the  armature  does  not  strike 
any  part  of  either  of  the  cores  (and  is  not  loosely  fixed 
where  it  is  hinged  to  the  upright  which  supports  it),  its 
movement  is  almost  noiseless  and  less  unsteady,  and  the 
Avorking  of  the  whole  instrument  is  more  satisfactory. 

the  U]iright  which  supports  it.  I  changed  the  manner  of  preventing  the 
turning  of  the  rod  of  the  interrui)ter,  and  to  this  rod  attached  the  hard'-rub- 
ber  piece  differently,  to  act  as  an  insulating  point ;  I  made  the  spiral  spring 
iff  lighter  brass  wire,  and  in  this  way,  and  with  the  advantages  gained  by 
the  rod  J,  I  was  enabled  to  make  such  adjustments  as  to  have  the  instru- 
ment operate  more  regularly  and  evenly,  and  the  armature  give  a  more 
distinct  blow  than  any  similar  or  other  mallet.  I  fitted  a  spiral  spring 
around  the  plunger  C,  to  keep  it  always  towards  the  armature  A.  I  so  fitted 
the  spring  L^  as  to  more  securely  keep  the  packing  instrument  D  against 
the  plunger  C.  Dr.  I.  F.  Wardwell  added  the  second  spring  L''^,  and  the 
two,  made  of  steel  and  prt)perly  tt  iniiered  and  fitted,  hold  the  packing  in- 
strument nicely  in  place.  Among  some  other  changes  which  I  made  in 
the  electro-magnetic  mallet  (and  which  can  be  seen  by  comparing  other 
instruments  with  the  one  here  illustrated,)  I  will  simply  mention  the  man- 
ner (though  perhaps  not  a  method  eniirely  original)  of  closing  the  point.- 
li)  make  the  I'ireuit  complete  under  the  slide  at  S. — Marshall  H.  Wkbb. 


80  NOTES    ON    OPERATIVE    DENTISTRY. 

The  device  J  is  an  attachment  by  A\'hich  the  stroke  ot 
the  armature  is  regulated  and  the  force  of  the  blow  to 
some  extent  controlled.  The  armature,  ordinarily,  ought 
to  have  no  more  play  or  movement  than  one-sixteenth  of 
an  inch  above  the  plunger,  but  when  a  little  heavier  than 
the  usual  blow  is  required,  without  recharging  two  of  the 
four  cells  of  the  battery  while  performing  an  operation 
(though  this  had  best  be  donej,  the  stroke  of  the  armature- 
should  be  lengthened  a  little  by  turning  the  nut  K  upon 
the  shaft  or  rod  J.  A  lighter  blow  can  be  had  (so  far  as 
changing  the  length  of  the  stroke  of  the  armature  aids  in 
this)  by  scre.wing  up  the  nut  K  to  a  certain  extent.  The 
hard-rubber  piece  I  is  inserted  to  lessen  the  sound  of  the 
armature  when  it  is  thrown  back  from  the  magnets. 

The  packing  instrument  D  passes  up  through  the  hard- 
rubber  hand-piece  P  :  it  is  kept  in  position  and  in  contact 
with  tlie  plunger  C  by  means  of  the  springs  L^,  L-,  and 
is  steadied,  directed,  and  turned  by  the  thumb  through 
the  opening  M.  The  hard-rubber  plunger  or  adjuster  (' 
should  be  so  regulated  by  means  of  the  screw  E  that 
when  the  packing  instrument  is  pressed  against  it  the 
armature  will  so  strike  the  same  that  there  shall  be  but 
space  sufficient  through  which  to  pass  a  piece  of  note 
paper  between  the  armature  (when  this  is  pressed  upon 
the  plunger)  and  the  rubber  plates  upon  which  it  strikes. 
The  rod  of  the  interrupter  should,  at  the  same  time,  be  s<  > 
adjusted  that  the  hard-rubber  point  V  just  touches,  but  is 
not  moved  by,  the  part  of  the  armature  or  mallet-head 
which  strikes  upon  it.  This  is  done  by  raising  or  lowering 
the  hard-rubber  part  F,  or  the  metallic  nut  in  which  it  is 
placed,  and  which  screws  on  to  the  rod  of  the  interrupter. 
"When  this  part  is  in  the  proper  position  the  small  nut  ad- 
joining must  be  screwed  tightly  against  it,  so  that  the 


NOTES    ON    OPERATIVE    DENTISTRY.  81 

part  may  be  firm  and  immovable  upon  the  rod  of  the 
interrupter  during  the  operation  of  the  instrument. 
When  the  spiral  spring  surrounding  the  rod  of  the  inter- 
rupter is  compressed  by  the  small  nut  IS",  it  accelerates  the 
movement  of  the  parts  and  more  rapid  blows  follow. 
When  the  pressure  upon  the  spring  is  lessened  by  un- 
screwing the  nut  which  regulates  it,  the  armature  plays 
more  slowly ;  but  it  should  be  remembered  that  the  force 
of  the  spring  must  be  sufficient  to  connect  the  platinum 
points  at  G,  and  thus  close  the  circuit  when  the  armature 
is  thrown  back  by  the  spring  H,  after  having  driven  the 
rod  of  the  interrupter  forward  and  broken  the  circuit. 
Greater  strength  of  the  spring  H,  which  throws  the 
armature  back  from  the  magnets  the  instant  the  circuit 
is  broken  or  interrupted  at  G,  is  more  necessary  when 
the  battery  is  freshly  charged  than  when  the  fluids  be- 
come mixed  and  the  power  is  thus  lessened.  The  tension 
can  be  regulated  accordingly  by  turning  the  nut  under 
the  spring  H ;  however,  it  is  rarely,  if  ever,  necessary  to 
do  this  when  the  force  of  the  spring  is  once  properly 
fixed. 

The  cord  0,  which  conducts  the  current  from  the  bat- 
tery to  the  mallet,  consists  of  two  sets  of  a  dozen  small 
copper  wires  each,  placed  near  together,  and  covered  and 
insulated  with  silk.  Each  of  the  tw^o  sets  of  wires  is  put 
into  the  end  of  a  small  brass  or  German-silver  tube,  and 
held  therein  by  soft  solder.  This  being  done,  the  two 
tubes  are  fixed  nearly  together  by  figure-of-eight  w^rap- 
ping,  then  another  covering  and  a  stitching  of  silk  thread, 
after  which  the  tubes  are  ready  to  be  slipped  tightly  on  to 
posts  fitted  to  them.  These  posts  are  on  the  side  of  the 
rubber  hand-piece  (See  Fig.  28).  Care  should  be  taken 
that  the  small  wires  do  not  break,  and  if  the  mallet  ceases 

6 


82 


NOTES    ON    OPERATIVE    DENTISTRY, 


to  operate  at  any  time,  a  careful  examination  of  this  part 

Fig.  30. 


fi' 


of  the  conducting  cord  should  first  be  made. 

Each  operator  who  uses  the  electro-magnetic  mal- 
let should  study  its  mechanism  and  endeavor  to  thor- 
oughly understand  the  instrument,  so  that,  if  at  any 
time  the  several  parts  require  re-adjusting,  he  shall 
have  made  himself  capable  of  doing  it.  If  the  direc- 
tions here  given  are  closely  followed,  there  should  be 
but  little  difficulty"  in  keeping  the  parts  of  the  instru- 
ment adjusted. 

The  packing  instruments  for  the  electro-magnetic 
mallet  (Fig.  30)  can  be  successfully  used  in  the 
filling  of  almost  any  cavity  when  prepared  as  herein 
described.* 

As  each  piece  of  Xo.  30  or  60  gold  for  large,  or 
foil  folded  to  So.  16  or  20  for  small,  fillings  is  passed 
over  the  flame  of  alcohol  and  introduced  intx)  the 
II  cavity  (either  by  an  assistant  with  light^pointed  foil- 
j    carriers,  or  by  the  operator  himself  with  the  pack- 


*No8.  5  and  11  of  this  set  are  pointn  designed  l»y  I>r.  C.  S.  Wardwell. 


NOTES    ON    OPERATIVE    DENTISTRY.  88 

ing  instrument)  and  simply  attached  to  the  part  (one  or 
two  pieces)  placed  by  hand  in  the  starting-point,  or  that 
already  there,  the  electro-magnetic  mallet  should  be  set 
in  operation,  and  the  finely-serrated  point  of  the  pack- 
ing instrument  touched  upon  or  placed  {not  pressed) 
against  the  gold  in  a  manner  similar  to  that  of  making 
dots  on  paper  with  a  pencil.  Light,  medium,  or  hard 
blows  can  be  made  without  changing  the  adjustments 
of  the  instrument,  as  fine  or  heavy  lines  are  made  on 
paper  with  a  pen.  When  the  electro-magnetic  mallet 
is  operated  and  guided  as  here  indicated,  gold  can  be 
carried  against  and  over  the  margins  (even  frail  edges)  of 
enamel  without  fracturing  them,  and  ^-ithout  the  pack- 
ing instrument  passing  otF  and  puncturing  the  rubber 
dam  and  wounding  tissue.  Almost  the  same  blow  is  re- 
quired throughout  each  and  every  operation,  because  the 
gold  should  be  solid  and  uniform  in  density;  hence  the 
action  of  the  battery  must  always  be  about  the  same  in 
intensity  and  constancy,  and  the  pieces  of  gold  for  a  given 
operation  ought  to  be  of  nearly  the  same  size;  all  foil 
should  be  cohesive,  as  well  as  be  made  compact.  By  a 
simple  touch  of  the  packing  instrument  each  piece  of 
cohesive  gold  is  made  to  adhere  to  that  placed  in  the 
starting-point;  a  slight  movement  of  the  slide  Q  by  the 
index  finger  (placed  through  the  ring  R)  connects  the 
platinum  points  and  thus  completes  the  circuit  at  S,  under 
the  slide,  and  the  armature  A  is  attracted  to  the  magnets 
B,  and  imparts  a  blow  to  the  packing  instrument  D 
through  the  hard-rubber  plunger  C,  and  at  the  same  in- 
stant touches  upon  the  part  F,  when  the  current  is  tem- 
porarily interrupted  or  cut  ofl:'  at  G.  The  successive  and 
rapid  recurrence  of  these  movements,  with  a  full  current 
of  electricity  in  a  properly-adjusted  electro-magnetic  mal- 


84 


NOTES    ON    OPERATIVE    DENTISTRY. 


let,  enables  an  operator,  with  careful  and  intelligent  guid- 
ance of  the  instrument,  to  go  over  the  whole  surface  of 
the  foil  much  better,  and  make  the  gold  more  solid  and 
uniform  in  density  with  greater  ease  and  rapidity  than  by 
any  other  known  method.  This  is  true  of  the  work  of 
the  electro-magnetic  mallet,  because  to  expel  the  air  from 
between  the  particles  of  foil  and  place  them  in  absolute 
contact  in  every  given  piece  or  body  of  gold^  or,  in  other 
words,  to  place  all  the  cohesive  particles  within  the 
"  sphere  of  influence  "  of  one  another,  a  certain  number 
of  blows  of  given  force  are  necessary;  and  to  thus  go 
over  the  whole  of  each  piece  being  impacted  by  any 
other  known  method  would  require  the  expenditure  of 

Fio.  31. 


more  time  and  greater  effort.  That  gold  be  made  com- 
pact it  is  not  so  desirable  that  a  heavy  blow  simply  be 
struck,  as  it  is  necessary  that  rapid,  regular,  and  only 
moderately  heavy  blows  be  skillfully  given  to  each  piece 
of  foil.  By  no  other  method  can  this  be  done  so  well 
and  80  perfectly  as  with  tlie  electro-magnetic  mallet. 

The  operator  ought  to  keep  the  battery  in  good  condi- 
tion and  charge  it  liimself,  unless  he  has  some  one  who 
is  very  careful  and  faithful,  and  who  appreciates  its  im- 
portance fully  enough  to  attend  to  it  properly  for  him. 

The  improved  Bunsen  cell,  with  a  large  carbon,  should 


NOTES  ON  OPERATIVE  DENTISTRY.  85 

be  used  for  the  electro-magnetic  mallet.  Four  cells  are 
required,  and  new  zincs  must  be  amalgamated  before  the 
battery  is  charged.  To  do  this,  place  one  of  the  zincs  in 
a  glass  jar  and  fill  in  the  water  till  it  is  on  a  level  with 
the  top  of  the  round  portion  of  the  zinc ;  then  lift  the 
zinc  out  of  the  water  and  pour  into  this,  little  by  little, 
three  and  a  half  fluidounces  of  sulphuric  acid.  Replace 
the  zinc  and  keep  it  in  the  solution  a  half-hour,  or  a  little 
longer, — until  the  zinc  is  so  acted  upon  by  the  acid  as  to 
take  up  the  mercury  then  to  be  dropped  upon  the  whole 
surface.  Do  this  with  each  of  the  zincs ;  then  pour  away 
the  solution  used,  and  charge  the  four  cells ;  thereafter 
two  of  the  cells  ought  to  be  recharged  each  week  alter- 
nately. 

The  whole  battery  should  be  kept  clean,  and  the  zincs 
must  be  well  amalgamated ;  mercury  should  be  dropped 
along  the  top  of  new  zincs  each  day  for  the  first  two  or 
three  weeks,  and  to  keep  them  bright  a  little  mercury 
ought  to  be  placed  upon  each  zinc  almost  every  time  the 
battery  is  recharged.  When  the  blocks  of  carbon  become 
disintegrated  and  the  edges  crumble,  or  the  surface  can 
be  easily  scraped  off,  new  carbons  must  be  substituted. 

The  eleciropoion  fluid — the  solution  for  the  porous  cups 
— is  made  in  a  large,  strong  glass  or  porcelain-lined  ves- 
sel, by  dissolving  a  half-pound  of  the  bichromate  of  pot- 
ash in  a  half-gallon  of  boiling  water.  When  this  solution 
is  cold,  add  ten  liuidounces  of  chemically-pure  sulphuric 
acid. 

In  charging  the  battery,  sufiicient  of  the  bichromate 
solution  should  be  put  into  each  porous  cup  (after  the 
carbon  is  placed  in  it)  to  till  it  within  about  an  inch  of 
the  top.  Each  zinc  being  placed  in  one  of  the  jars,  and 
the  porous  cups  containing  the  carbon  and  solution  being 


86  NOTES    ON    OPERATIVE    DENTISTRY. 

put  in  position  as  illustrated  in  Fig.  31,  pour  in  enough 
water  to  fill  each  glass  jar  to  within  about  a  sixteenth  of 
.an  inch  of  the  top  of  the  cylindrical  portion  of  the  zinc; 
then  remove  the  porous  cup  (with  the  carbon)  and  the 
zinc,  and  slowly  pour  one  and  a  half  fluidounces  of  chemi- 
cally-pure or  two  ounces  of  the  ordinary  commercial  sul- 
phuric acid  into  the  water  in  the  jar ;  after  which  replace 
the  zinc  and  porous  cup.  (In  place  of  this  a  solution,  con- 
sisting of  nine  parts  of  water  to  one  of  sulphuric  acid,, 
may  be  poured  into  the  glass  jar  to  just  cover  the  zinc.) 
The  solutions  should  be  on  a  level,  one  with  the  other. 
Care  must  be  taken  that  none  of  the  bichromate  solution 
is  poured  into  the  glass  jars  in  charging  the  porous  cup ; 
also,  that  the  acid  solution  does  not  get  into  the  porous 
cups.  Kow  connect  the  four  cells  (carbon  to  zinc).  Con- 
nect the  conducting  cord  to  the  mallet,  and  one  of  the  two 
sets  of  wires  of  the  other  end  of  this  cord  (or  additional 
conducting  wires  if  they  are  required)  to  the  carbon  of 
the  first  cell,  and  the  other  set  to  the  zinc  of  the  fourth  or 
last.  The  copper  wire  connecting  the  carbon  of  one  to 
the  brass  post  attached  to  the  zinc  of  the  next  cell  must 
not  touch  anything  at  any  other  point.  The  parts  where 
the  zinc  of  one  cell  is  connected  with  the  earbon  of  the 
next,  etc.,  and  those  where  the  wires  connect  with  the 
mallet,  should  be  bright  and  tight.  With  all  this  properly 
done,  the  battery  is  always  in  readiness. 

ADDITIONAL    DIRECTIONS    FOR    OPERATINc;    THE    ELECTRO- 
MA(iNETIC    MALLET    AS    IT    IS    NOW    MADE.* 

Connect  the  instrument  with  the  battery  by  passing  the 
tubes  attached  to  the  silk-covered  cord  A  over  the  two 


*The  electro-magnetic  mall(;t  manufactured  by  The  S.  S.  White  Dental 
Manufacturing  Co.,  and  here  illustrated,  is  made  after  the  pattern  of  the 


NOTES    ON    OPERATIVE    DENTISTRY. 


87 


pins  (on  the  reverse  side  of  the  instrument,  but  not  seen 
Fio.  32.  in   the   cut).     Place]  the   index    finger 

through  the  ring  B,  resting  the  mallet* 
in   the   hand;    gentle   pressure  of  the 
end   of  the  finger  upon  the  flange  of 
the  slide  C  completes  the 
circuit.     The  armature  D, 
being  thus  attracted  to  the 
electro-magnets  E,  strikes 
upon  the  end  of  the  hard- 
rubber  plunger  F,  against 
which  rests  the  swell  end  of 
the  packing  instrument  H. 
Every  time  the  armature 
is   attracted    to   the   mag- 
nets it  strikes  the  plunger 
F  (which   is    adjusted   by 
the    screw-nut     G),     and, 
at    the    same   time,   the   rod   of    the   in- 
terrupter I,  thus  disconnecting  the  plati- 
num points  at  K.     The  armature  is  then 
forced   away   fi-om   the   magnets   by   the 
spring  L,  and  is  caught  at  M ;  the  rod  of 
the  interrupter  is  carried  back  to  its  posi- 


instrument  shown  in  Fig.  29.  The  shape  of  some  of 
the  parts  has  been  modified  by  the  manufacturer, 
but  this  does  not  interfere  with  the  working  of  the 
mallet;  however,  thej parts  are  lettered  dififerently 
and  a  different  description  of  them  must  he  given.  In 
the  cut  the  armature  D  is  purposely  shown  too  far 
above  the  magnets  E,  in  order  that  the  position  of  the 
spring  L  may  be  seen,  the  space  between  the  arma- 
ture and  the  magnets  being  actually  not  over  the  six- 
teenth of  an  inch  at  the  interrupter  I. 


88  NOTES    ON    OPERATIVE    DENTISTRY. 

tion  by  the  recoil-spring  N,  whicli  surrounds  it,  bring- 
ing the  platinum  points  in  contact  again,  the  instrument 
^ being  thus  kept  in  operation  as  long  as  pressure  is  con- 
tinued upon  the  flange  of  the  slide.  The  length  of  stroke 
of  the  armature  is  regulated  by  the  nut  0,  acting  upon 
and  firmly  setting  the  rod  P.  The  hard-rubber  cushion 
at  M  lessens  the  sound.  The  packing  instrument  H  is 
controlled  by  the  thumb  through  the  opening  R.  The 
springs  Q,  Q  keep  the  instrument  in  contact  with  the 
plunger  F. 

When  the  mallet  needs  adjustment  press  the  instru- 
ment H  against  the  plunger  F,  this  being  so  regulated 
by  the  screw-nut  Gr  that  when  the  armature  is  pressed 
towards  the  magnets  it  comes  in  contact  with  the  plunger 
sufficiently  to  leave  only  enough  room  between  the  arma- 
ture-plate and  the  rubber  plates  beneath  to  pass  a  piece 
of  thin  writing-paper,  while,  at  the  same  time,  the  rod  of 
the  interrupter  I  should  be  so  adjusted  that  the  arma- 
ture-plate shall  just  touch  it.  The  spring  surrounding  the 
rod  of  the  interrupter  is  regulated  by  the  small  nut  at  S. 
The  tension  of  the  spring  must  be  sulficient  at  all  times 
to  bring  the  platinum  points  at  Iv  into  close  contact. 


FILLING  CAVITIES  IN  MASTICATING 
SURFACES. 


'TTT'HEX  solution  of  the  lime-salts  of  the  enamel  and 
^  ^  dentine  has  advanced  along  a  fissure  or  in  a  sul- 
cus or  the  sulci  of  a  bicuspid  or  molar,  the  rubbei-  dam 
should  be  neatly  applied  to  the  tooth  in  which  the  cavity 
is  found,  as  well  as  to  the  one  or  more  adjoining,  so  that 
the  parts  shall  be  kept  dry  and  be  brought  more  plainly 
into  view.  The  saliva  remaining  in  a  cavity  or  about  the 
teeth  is  best  taken  up  on  Japanese  bibulous  paper,  ap- 
plied in  the  form  of  pellets  with  foil-carriers  (Fig.  33). 


If  decay  has  made  consideral>le  progress  beneath,  and 
the  dentine  is  so  dissolved  away  and  discolored  as  to  be 
seen  through  the  plate  of  the  translucent  enamel,  the 
cavity  should  be  opened  into  by  means  of  enamel  chisels 
(Fig.  34).  The  softer  portions  of  the  decayed  dentine 
should  then  be  removed  with  sharp  excavators  (Fig.  35), 
the  fissures  sutfieiently  opened,  and  anchorage  for  the 
filling  made  with  keen  burs  operated  by  a  dental  engine. 
The  walls  should  be  well  shaped,  with  very  little  under- 
cut; the  margins  of  enamel  evenly  and  smoothly  finished 
with  fine,  sharp  burs ;  a  starting-point  made  (if  one  of 
the  fissures  does   not  serve  the  same  purpose),  and  the 

89 


90 


NOTES    ON   OPERATIVE    DENTISTRY. 


whole  cavity  so  prepared  (Fig.  36,  6)  that  all  the  gold 
Fig.  34*  Fig.  SS.f 


>'* 


li 


■^  '^ 


11 


may  be  thoroughly  con- 
densed with  the  mallet. 
If,  in  making  gold  com- 
pact, any  part  or  the  whole 
of  it  becomes  displaced, 
the  mass  ought  to  be  re- 
moved at  once ;  otherwise 
the  filling  would  be  imper- 
fect. Gold  in  the  form  of 
cylinders  and  pellets,  and 
when  in  a  non-cohesive 
condition,  may  be  used  so  as  to  prevent  decay  in 
some  so-called  simple  cases;  but  when  really  fine 
or  first-class  operations  are  to  be  performed,  foil 
ought  to  be  so  carefully  prepared,  introduced, 
and  solidified  that  the  operator  can  be  positive 
■  that  each  piece  has  been  firmly  anchored  in 

*  The  first  of  these  instruments  belongs  to  the  set  devised 
by  the  author  for  the  electro-magnetic  mallet,  in  which 
chisels  can  be  operated  nicely  and  effectively. 

f  This  illustration  shows  some  of  the  most  useful  forms  of 
excavators. 


NOTES    ON    OPERATIVE   DENTISTRY. 


91 


Fio.  37.*— The  S.  S.  White  Dental  Engine. 


Fig.  38.— Cone- 
Journal 
Hand-Pieck. 


The  dental  engine  here  illustrated  (Fig.  37j  is  so  well  and  favorably 


92  NOTES    ON    OPERATIVE   DENTISTRY. 

place,  or  has  adhered  to  that  already  in  position,  and  being 
certain  of  this  the  whole  filling  can  be  made  solid  and 
uniform  in  density,  and  the  organ  operated  upon  fully 
restored  to  usefulness.  The  success  of  an  operation,  how- 
ever, depends  more  on  the  skill  of  the  operator  than  on 
the  material  used  or  the  means  employed. 

Fillings  in  the  masticating  portions  of  the  teeth  should 
be  trimmed  down  even  with,  but  not  below,  the  sur- 
rounding edges  of  enamel,  and  made  concave  in  the 
central  parts  (as  in  nature),  with  fine,  sharp  burs.  Burs 
rather  than  corundum  cones  should  be  used  for  this  pur- 
pose, so  as  to  avoid  the  cutting  and  thus  the  change  of 
form  of  the  cusps,  which  cutting  of  cusps  too  often  dis- 
figures and  impairs  the  usefulness  of  the  masticating  sur- 
faces of  the  teeth.  The  final  finish  of  the  gold  should  be 
done  with  pumice  on  points  of  wood  of  proper  shape 
held  in  a  mandrel  and  operated  (like  the  burs)  with  a 
dental  engine  (Fig.  37). 


known  that  nothing  need  he  said  regarding  it,  but  the  electro-magnetic 
burring  engine,  in  some  respects,  has  advantages  other  such  instruments 
do  not  have.  It  may  either  be  suspended  or  held  in  the  hand  conven- 
ient!}', and,  by  the  use  of  the  electric  engine,  the  operator  escapes  "the 
tyranny  of  the  treadle."  It  ciin  be  used  with  satisfaction  only  by  those 
who  understand  something  of  electricity,  and  who  exercise  weekly  care 
to  keep  the  battery  properly  charged  and  in  good  condition.  The  elec- 
tric engine  operates  nicely  when  connected  with  the  same  battery  that  is 
used  for  the  electro-magnetic  mallet,  but  if  more  power  is  needed  (as  when 
both  engine  and  nnillet  are  connected  with  the  same  four-cell  battery  and 
used  every  day  steadily),  a  lifth  cell  should  be  added.  This  fifth  cell 
can  be  and  ouglit  to  be  so  arranged  as  to  be  connected  or  disconnected 
with  the  other  four  cells  almost  instantly  at  tlie  will  of  the  operator. 
Many  improvements  have  been  made  in  the  construction  of  the  electric 
engine,  niaking  it  compact  and  convenient  in  form;  the  new  Cone- 
Journal  Hand-pie(;(;  (Fig.  38)  can  as  well  be  fitted  to  it  as  to  the  S.  S 
White  Dental  Engine.  I 


FILLING  CAVITIES  WITHIN  LABIAL  AND 
BUCCAL  WALLS. 


WKF^N  solution  of  enamel  takes  place  within  the 
labial  portion  of  an  incisor  or  cuspid,  or  on  the 
buccal  surface  of  a  bicuspid  or  molar,  and  the  cavity  ex- 
tends beneath  the  margin  of  the  gum  (as  also  in  some 
cavities  within  approximal  walls),  it  is  sometimes  difficult 
to  apply  the  rubber  dam.  In  these  cases  a  ligature  of 
waxed  floss-silk  should  be  placed  twice  around  the  tooth 
to  be  operated  upon,  and  after  it  is  secured  to  the  adjoin- 
ing tooth  or  teeth,  and  while  holding  the  ends  of  the 
ligature  in  the  left  hand  (and  just  before  tying  the  last 
part  of  the  surgeon's  knot  which  is  to  tighten  the  liga^ 
ture),  both  it  and  the  rubber  should  be  pressed,  ^ig-  ^^■ 
with  a  flat  burnisher  (Fig.  39),  above  the  margin  of  i^ 
the  cavity  so  as  to  bring  it  into  view  and  secure 
dryness.  In  such  cases  it  is  often  necessary  to  hold 
a  ligature,  together  with  the  rubber  dam,  above 
the  margin  of  the  gum  by  means  of  a  broad- 
pointed  excavator.  Previous  to  commencing  an 
operation  it  is  desirable  to  have  everything  at 
hand  that  may  be  required.  A  suitable  clamp 
(preferably  from  the  Delos  Palmer  set)  should  be 
used  in  many  of  these  cases,  but  more  especially  when 
the  rubber  dam  is  to  be  applied  to  the  upper,  and  always 
when  applying  it  to  the  lower,  molars.  The  clamp 
should  first  be  adjusted  to  the  tooth,  and  the  rubber  then 

93 


94 


NOTES    ON    OPERATIVE   DENTISTRY. 


stretched  over  it  from  the  posterior  to  the  anterior  part, 
and  also  applied  and  fastened  with  ligatures  of  waxed 
floss-silk  to  the  adjoining  tooth  or  teeth.  After  the  re- 
moval of  the  softer  portion  of  the  decayed  dentine  with 
sharp  excavators,  the  margins  of  the  cavities  just  referred 
to  should  be  evenly  and  smoothly  finished,  and  the 
enamel  undergoing  solution  should  be  removed  by  means 
of  fine,  keen  burs  (Fig.  40).     In  some  cases  discoloration 


Fig.  40.* 
Cavity  Instruments. 


Finishing  Burs. 


of  enamel  should  be  removed  and  the  margins  of 
cavities  made  even  and  smooth  with  corundum 
cones  and  Hindostan  stones  (Figs.  43  and  44) ;  these 
being  kept  wet  with  water  from  a  drop  tube  (Fig.  41).  A 
magnifying  glass  should  be  used  to  examine  the  margins 

Fig.  41. 


of  all  cavities  in  order  that  they  may  be  made  as  perfect 
as  possible.  A  slight  undercut  should  be  made  around 
the  cavity  along  the  boundary-line  between  the  enamel 
and  dentine,  and  a  starting-point  drilled  in  the  dentine 
just  inside  the  enamel  in  a  direction  where  there  is  no 
liability  of  the  drill  getting  into  too  close  proximity  to  the 
pulp.     The  first,  second,  and  sometimes  a  third  piece  of 


*  These  cuts  illustrate  many  of  the  most  useful  forms  of  burs. 


NOTES    ON    OPERATIVE   DENTISTRY. 


95 


foil  should  be  placed  in  the  starting-point  by  hand  with 
a   suitable   instrument  (Fig.  42),  and  after      Fig.  42* 
that  has  been  inserted  all  the  gold  ought  to 
be  made  compact  with  the  mallet.     When 
the  cavity  is  entirely  filled  the  gold  should 
be  trimmed  down  to  conform  to  and  yet  be 
flush  with  the  surrounding  surface  of  en- 
amel, by  means  of  sharp  chisels  or  files,  fine 
burs,  small  corundum  wheels,  and  Hindostan 
stones  (Figs.  43  and  44).    All  this  should  be 
done  previous  to  the  removal  of  the  rubber 
dam,  after  which  the  gold  and  surrounding 
enamel  ought  to  be  finely  finished  with  pul- 
verized pumice  applied  on  wood,  leather,  or  rubber 
points  or  cones. 

Fig.  43. t 


*  From  the  set  of  instruments  devised  by  the  author  for  the 
electro-magnetic  mallet. 

f  These  cuts,  Figs.  43  and  44,  show  the  most  useful  forms  and  sizes  of 
corundum  wheels  and  cones  and  Hindostan  stones. 


PIECES  OF  PORCELAIN  FOR  FILLING 
CAVITIES  OF  DECAY. 


Ij^OR  a  number  of  years  a  few  operators  have  occa- 
-■-  sionally  inserted  a  piece  of  carefully-selected  porce- 
lain in  a  large  cavity  within  the  labial  walls  of  incisors 
or  cuspids  with  oxychloride  of  zinc,  and  afterwards  filled 
in  foil  between  the  porcelain  and  the  margin  of  the  enamel, 
thus  presenting  only  a  narrow  line  of  gold  to  view.* 

During  and  after  the  year  1870,  when  he  -was  prac- 
ticing in  Reading,  Pa,,  Dr.  F.  Hickman  frequently  used 
pieces  of  porcelain  crowns  in  filling  large  cavities  of  de- 
cay in  the  buccal  and  masticating  surfaces  of  molars. 
These  pieces  were  selected  from  porcelain  crowns  made 
for  other  work ;  were  fitted  accurately  to  the  margin  of 
the  cavity  to  be  filled,  and  inserted  in  either  gutta-percha 
or  oxychloride  of  zinc,  the  plastic  filling  the  interstices 
between  the  porcelain  and  the  margins  of  the  cavity.  Dr. 
Hickman  did  not  build  in  gold  between  the  porcelain  and 
enamel  afterwards,  how^ever,  as  in  cavities  within  the 
labial  walls  of  incisors  or  cuspids. 

Various  sizes  and  different  forms  of  porcelain  have 
since  been  made  for*filling  cavities,  and  these  pieces  are 
so  well  shaped  that,  with  slight  beveling  of  the  edges, 
but  little  trimming  is  necessary  to  prepare  them  for  inser- 
tion.    Some  of  these  have  a  platinum  pin  inserted  in 


*It  has  been  stated  that  Dr.  B.  Wood,  in  1862,  suggested  to  Dr.  S.  S. 
White  the  idea  of  using  porcelain  for  such  purposes. 
96 


NOTES    ON    OPERATIVE    DENTISTRY.  97 

them,  but,  while  these  are  the  best  so  far  devised  for  fill- 
ing large  crown  cavities,  they  can  rarely  be  used  except 

in  pulpless  molars. 

Fig.  45. 


In  inserting  pieces  of  porcelain,  the  shade  and  shape  of 
the  piece  to  be  used  in  each  case  must  first  be  carefully 
selected,  after  which  the  rubber  dam  ought  to  be  applied, 
the  cavity  prepared,  and  the  porcelain  fitted  and  inserted. 
If  the  piece  is  to  be  placed  in  a  cavity  in  the  masticating 
surface  of  a  molar  the  entire  cavity  ought  to  be  filled 
with  oxychloride  or  oxyphosphate  of  zinc,  and,  while  the 
cement  is  yet  sufficiently  plastic,  the  porcelain  must  be 
pressed  to  place,  and  the  surplus  material  that  escapes 
should  be  trimmed  away  at  once,  thus  exposing  the  mar- 
gins to  view.  After  allowing  ample  time  for  the  cement 
to  harden,  the  rubber  dam  should  be  removed  and  the 
porcelain  trimmed  down  with  corundum  wheels  till 
proper    occlusion    of    the    teeth    is    obtained.      Fig.  46.* 

Oxychloride  and  oxyphosphate  of  zinc,  as 
well  as  gutta-percha,  wear  away,  but  when 
only  a  narrov/  line  of  the  material  is  left 
between  the  enamel  and  the  porcelain,  attrition 
does  not  impair  the  operation,  and  further 
decay  is  not  likely  to  take  place. 

Gutta-percha  ought  to  be  used  in  the  filling 
of  cavities  within  the  buccal  walls  of  molars,  and  especi- 

*  Section  of  a  molar  showing  the  position  of  a  piece  of  porcelain  in 
oxychloride  of  zinc.  Tlie  thickness  of  dentine  remaining  below  the 
cement  is  shown  where  a  part  of  the  pulp-chamber  was  exposed  in  the 
preparation  of  the  specimen. 


98  NOTES    ON    OPERATIVE    DENTISTRY. 

ally  where  the  cavity  to  be  filled  extends  to  or  under  the 
margin  of  the  gum,  because  this  material  is  not  dissolved 
and  washed  away  by  the  fluids  of  the  mouth.  After  the 
piece  of  porcelain  has  been  properly  fitted,  it  should  be 
heated  just  enough  to  soften  the  gutta-percha  previously 
placed  in  the  cavity,  to  allow  of  its  being  pressed  at 
once  to  place.  After  trimming  away  the  gutta-percha  to 
the  margin  of  enamel  and  porcelain,  first  with  a  warm, 
flattened  burnisher,  and  then  with  chloroform  applied  on 
pellets  of  Japanese  bibulous  paper,  the  operation  is  com- 
plete, and  the  rubber  dam  should  be  removed.  Even 
though  the  surface  of  the  porcelain  be  on  a  line  with  that 
of  the  enamel  surrounding  it,  the  gloss  left  from  the 
burning  of  the  piece  should  then  be  removed  with  Hin- 
dostan  stones,  because  a  less  artificial,  and  therefore  a 
finer,  appearance  in  the  mouth  is  presented. 

Previous  to  filling  with  gutta-percha,  or  with  any 
material  other  than  oxy chloride  or  oxyphosphate  of  zinc, 
one  of  these  cements  ought  to  be  placed  in  the  bottom  of 
all  deep  cavities  as  a  non-conductor  of  the  currents  incited 
by  heat  and  cold  in  the  dentinal  fibers,  in  order  that  the 
pulp  so  nearly  exposed  may  be  better  protected  than  by 
gutta-percha,  or  that,  after  a  metallic  substance  is  inserted, 
thermal  changes  may  not  produce  shock. 

Pieces  of  porcelain  cannot  be  easily  inserted  in  any 
but  what  may  be  called  large-medium  or  in  extensive 
cavities  of  decay,  and  it  is  scarcely  necessary  to  try  in- 
serting them  in  other  than  these,  because  it  usually  re- 
quires comparatively  little  time  to  fill  well  with  gold,  by 
the  aid  of  the  electro-magnetic  mallet,  small  cavities 
in  the  masticating  and  buccal  surfaces  of  molars  and  bi- 
cuspids. 

"When  cavities  are  carefully  prepared  and  the  pieces  of 


NOTES    ON    OPERATIVK    DENTISTRY.  99 

porcelain  are  properly  fitted,  inserted,  and  finished,  these 
operations  not  only  present  a  finer  appearance  and  pro- 
tect the  margins  of  enamel  better  than  fillings  made  of 
amalgam,  but  they  are  really  more  durable  than  fill- 
ings of  any/plastic  substance  or  any  known  material 
except  gold. 


FILLING  CAVITIES  WITHIN  APPROXIMAL 
WALLS. 


QiOLUTION  of  the  basis-substance  of  tbe  enamel 
^^  almost  invariably  commences  at  or  near  the  part 
of  the  tooth  which  is  in  contact  with  its  neighbor  on 
either  side,  and  soon  extends  along  the  whole  approximal 
surface,  involving  the  dentine,  in  which  tissue  decay 
progresses  rapidly.  When  this  takes  place  upon  the 
approximal  surfaces  of  the  incisors  and  cuspids  they 
should  be  separated  by  wedging  with  wood,  or  by  having 
previously  pressed  linen  tape  qy  cotton  between  them. 
Wlien  the  necessary  space  has  been  made  in  this  way, 
particularly  between  the  incisors  and  cuspids,  white  gutta- 
percha should  be  placed  in  the  cavity  or  cavities,  also  in 
the  space  gained,  and  allowed  to  remain  a  day  or  two, 
imtil  the  irritation  incited  by  the  wedging  has  subsided. 
Rubber  ought  not  to  be  used  for  pressing  teeth  apart,  for 
the  reason  that  it  causes  far  more  irritatioin  than  other 
substances.  It  is  oftentimes  best  to  place  a  wedge  of 
orange  or  boxwood  between  the  teeth,  even  after  having 
pressed  them  apart,  not  only  to  gain  more  space  than  that 
obtained  from  previous  wedging,  but  to  arrest  their  ten- 
dency to  approach  each  other,  and  to  steady  the  organs 
for  the  performance  of  the  operation ;  particularly  if  the 
irritation  from  the  slow  wedging  has  not  passed  away,  so 
as  to  admit  of  the  insertion,  by  the  aid  of  the  mallet,  of 
all,  or  nearly  all,  the  gold.  When  the  required  space  has 
been  gained,  the  rubber  dam  should  be  applied;  the  quick 
100 


NOTES  ON  OPERATIVE  DENTISTRY. 


101 


wedging  should  be  resorted  to,  if  found  necessary,  and 
the  operation  commenced.  The  cavity  sliould  be  care- 
fully prepared  and  the  edges  of  enamel  smoothly  and 
evenly  finished;  a  slight  groove  or  undercut  should  be 
made  toward  the  cutting-edge  and  at  the  ^lo-  47.* 

cervical  wall,  and  a  starting-point  drilled 
in  this  wall  toward  the  palatal  edge. 
All  the  anchorage  should  be  made  in 
the  dentine,  just  inside  the  line  of  junc- 
tion of  this  tissue  with  the  enamel.  In 
the  filling  of  these  cavities,  particularly 
the  small  ones,  more  than  those  in  any 
other  location,  it  is  necessary  to  use 
what  is  known  as  "  hand-pressure," 
and  pack  some  of  the  gold  (mainly  into 
the  undercuts)  with  small  curved  instru- 
ments having  fine  and  sharp  serrations 
(Fig.  48).  Cohesive  gold  can  be  very 
successfully  used  in  these  cases,  as  well 
as  in  all  others,  but  it  should  be  pre- 
pared from  a  half-leaf  of  light  foil,  such 
as  Xo.  4,  so  folded  as  to  be  equivalent 
to  Xo.  12  or  Xo.  16,  and  then  cut  into 
strips  about  a  half-line  wide.  In  many 
cavities  of  this -class,  as  well  as  in  most 
others,  all  the  gold  can  be  best  impacted 
by  the  quick,  decided,  even  blow  given 
by  the  usual  one-sixteenth  inch  stroke 
of  the  electro-magnetic  mallet.  The 
whole  operation  of  inserting  the  gold,  as  before  described, 
can  be  so  completed  that  there  shall  be  perfect  restora- 
tion of  contour  of  missing  tissue. 


^S9 


*  Fig.  47  shows  a  good  form  of  wedge-forceps  devised  by  Dr.  Corydon 

Palmer. 


102 


NOTES    ON    OPEEATIVE    DENTISTRY. 


Fig.  48.* 


"1" 


After  the  preparation  of  cavities  such  as  those  just 
referred  to,  particularly  the  larger  ones,  and  previous  to 
the  insertion  of  the  gold,  the  edges  of  enamel 
forming  the  margin  should  be  made  smooth 
and  be  evenly  finished,  but  not  rounded, 
with  emery-cloth;  first  a  narrow  strip  cut 
from  No.  J,  and  then  one  from  ^o.  0. 
When  the  gold  has  been  made  compact  and 
its  siirface  has  been  trimmed  down  to  the  edge 
of  the  enamel  which  surrounds  it,  and  the 
whole  has  been  so  shaped  as  to  conform  to 
the  contour  of  the  tissue  which  the  gold  is 
to  substitute, — upon  the  approximal  surface 
and  labial  edge  by  means  of  a  No.  1  or  No.  0 
Froid  file,  and  upon  the  palatal  portion  with 
a  fine  bur, — strips  of  fine  emery-cloth  should 
be  so  manipulated  as  to  perfectly  finish  the 
surface  of  the  gold,  and  leave  the  parts 
beautifully  formed.  All  this  can  best  be 
done  previous  to  the  removal  of  the  rub- 
l)er  dam,  after  which  the  filling  should  be 
finished  by  the  use  of  finely  pulverized 
pumice,  and  then  silex,  each  mounted  and 
applied  upon  fine  linen  tape.  Rouge  may 
then  be  applied  upon  a  strip  of  fine  cha- 
mois-skin. When  the  gold  is  made  solid 
throughout,  pumice,  silex,  and  rouge  leave 
a  finer  finish  than  the  burnisher,  but  not  so 
brio-ht  a  luster.  The  burnisher  need  not 
be  used,  and   should   not,  for  the   reason 


*  Small  curved  in.strumcnt.s,  right  and  left,  with  fine,  sharp  serrations. 
NoTK. — All  the  instruments   illustrated    in    this  book  are  similar  to 
those  used  by  the  author  in  his  practice. 


NOTES  ON  OPERATIVE  DENTISTRY.  103 

that,  besides  the  undesirable  luster  which  it  leaves,  gold 
that  is  made  compact  at  every  part  with  the  mallet  can 
have  but  very  little,  if  any,  impression  made  upon  it  by 
the  burnisher. 

All  operations  ought  to  be  pt'rformed  artistically  and 
made  as  nearly  perfect  as  possible,  so  that  if  gold  is 
exposed  to  view  its  appearance  shall  be  beautiful  and 
rather  pleasing  than  otherwise. 


PREPARATION  OF  CAVITIES  FOR  RESTOR- 
ATION OF  CONTOUR. 


"TTTHEF  solution  of  the  enamel  of  the  approximal 
'  ^  surface  of  a  bicuspid  or  molar  has  taken  place, 
and  the  dentine  has  also  undergone  dissolution,  separation 
by  pressure  is  necessary,  as  in  the  case  of  the  incisors. 
Though  sufficient  space  may  be  gained  between  the 
incisors  by  quick  wedging,  yet  such  wedging  of  bicuspids 
and  molars  can  not  be  done  so  easily  and  rapidly  as  in  the 
case  of  incisors,  especially  when  the  cavity  extends  almost 
to  the  margin  of  the  cementum.  In  such  cases,  the  gold 
should  be  built  into  and  from  the  starting-point,  along  the 
cervical  wall  and  grooves,  and  to  the  part  where  the  con- 
vexity of  the  filling  must  be  gradually  increased.  When 
so  much  of  the  gold  has  been  inserted  with  the  mallet,  and 
smoothly  finished  with  separating  or  other  files  (care  being 
taken  not  to  cut  the  rubber  dam),  a  wedge  of  hard  wood 
ought  to  be  placed  between  the  gold  and  the  tooth  adjoin- 
ing, and  sufficient  space  thus  secured  to  enable  the  opera- 
tor to  so  complete  the  filling  that  there  shall  be  no  spaces 
between  the  teeth,  except  at  and  near  the  necks.  If  the 
operator  cannot  do  this,  a  wedge  of  boxwood  should  be 
inserted  from  the  neck  to  a  point  midway  between  it  and 
the  masticating  surface  of  the  tooth,  and  cut  away  with 
burs  to  the  form  the  filling  should  have;  but  such  an 
appliance  ought  not  to  be  depended  upon  to  retain  any 
portion  of  the  gold.     Unless  separation  by  pressure  is 

104 


NOTES    ON    OPERATIVE    DENTISTRY.  105 

made  in  some  such  manner  as  indicated,  the  gold  cannot 
be  80  finished  as  to  have  the  teeth  come  closely  together, 
and  prevent  the  wedging  of  food  between  them.  Pressure 
ought  not  to  be  rudely  made  or  too  long  continued,  else 
circulation  in  the  capillaries  and  protoplasmic  bodies  of 
the  pericementum  may  be  so  interfered  with  as  to  prevent 
the  return  of  the  parts  to  the  normal  condition  after  the 
wedge  has  been  removed. 

After  sufficient  space  has  been  gained,  the  rubber  dam 
should  be  applied  to  the  two  teeth  separated  by  pressure, 
and  to  the  tooth  adjoining  each,  that  those  pressed  apart 
may  not  come  together  during  the  performance  of  the 
operation,  or  the  insertion  and  finishing  of  the  filling, 
and  that  the  organs  may  be  the  better  operated  upon. 

All  cavities,  wherever  located,  ought  always  to  be  made 
accessible.  A  cavity  within  the  approximal  wall  of  a 
bicuspid  or  molar  should  be  opened  into  from  the  masti- 
cating surface  (Fig.  36,  a,  b,  and  c),  except  in  rare  cases, 
because,  even  when  there  appears  to  be  but  little  solution 
of  the  lime-salts,  this  surface  would  be  almost  reached 
upon  the  perfect  removal  of  the  tissue  where  dissolution 
of  the  basis-substance  had  taken  place,  and  the  plate  of 
enamel  would  be  liable  to  fracture,  if  hard  substances 
were  to  come  in  contact  witli  it  during  the  mastication  of 
food.  It  is  far  better  to  cut  away  the  enamel  between  the 
cavity  and  the  masticating  surface,  because  a  clearer  view 
is  thus  obtained,  and  the  entire  operation  can  be  per- 
formed in  a  satisfactory  manner,  with  certainty  of  a  good 
result.  In  addition  to  this,  the  adjoining  fissure  or  sulcus 
is  usually  imperfect,  and  it  should  be  prepared  (as  at  a  and 
b,  Fig.  36)  and  filled  in  connection  with,  and  at  the  time 
of,  the  performance  of  the  operation  within  the  approx- 
imal  wall.     That   operations   may   be   successful,    every 


106         NOTES  ON  OPERATIVE  DENTISTRY. 

cavity  must  be  so  prepared  that  no  decalcified  or  par- 
tially decalcified  tissue  remains,  except  there  he  a  little 
discolored  dentine  near  the  pulp,  and  that  should  be  left 
for  its  protection.  The  margins  of  enamel  should  be 
slightly  beveled  when  gold  is  to  be  placed  over  them, 
and  they  ought  always  to  be  made  smooth  and  even  with 
fine,  sharp  burs,  files,  and  emery-cloth.  A  groove,  about 
the  sixty-fourth  of  an  inch  deep,  should  be  cut  along  each 
wall  of  the  cavity  (c.  Fig.  36),  and  must  be  made  in  the 
dentine  within  and  near  the  line  of  both  the  buccal  and 
palatal  or  lingual  walls  of  enamel.  It  ought  to  extend 
from  the  masticating  surface  to  (but  not  along)  the 
cervical  wall,  except  in  some  cavities  in  the  incisors, 
because  of  there  not  being  such  a  body  of  tissue  at  that 
part  as  to  make  it  safe  to  remove  any  of  it  for  the  pur- 
pose named.  The  greatest  pain  is  felt  when  the  operator 
reaches  the  interzonal  layer,  because  it  is  this  part — along 
the  boundary-line  of  dentine  toward  the  enamel — where 
there  is  more  li^dng  matter  than  elsewhere  in  the  dentine 
or  in  the  enamel.  The  neck  of  a  tooth  is  also  very  sensi- 
tive, for  the  reason  that  this  part,  too,  is  supplied  with  so 
many  fine  fibers  of  living  matter.  Care  ought  therefore 
to  be  taken  tliat  no  more  cutting  than  is  absolutely 
necessary  be  done  about  this  part. 

En  the  preparation  of  a  cavity  within  the  approximal  walls 
of  enamel  of  a  bicuspid  or  molar,  enough  of  the  tissue 
toward  the  buccal,  palatal,  or  lingual  wall  must  be  cut  away 
to  free  the  edges,  thus  enabling  the  operator  to  so  restore 
the  contour  of  the  parts,  and  so  finish  the  filling  or  fillings 
as  to  keep  the  margins  of  enamel  from  contact  with  the 
tooth  adjoining.  This  is  the  only  way  to  keep  the  mar- 
gins of  enamel  permanently  separated,  and  thus  prevent 
extension  of  decay. 


NOTES   ON   OPERATIVE    DENTISTRY.  107 

If  solution  of  eniimel,  or  decay,  does  not  extend  to  or 
beneath  the  margin  of  the  gum  (and  especially  if  calcifi- 
cation is  imperfect),  both  the  enamel  and  dentine  of  the 
approximal,  as  well  as  of  the  buccal,  surface  of  the  tooth 
being  operated  upon  ought  to  be  cut  away  with  fine  burs 
to  fully  the  thirty-second  of  an  inch  above  the  part  where 
the  gum  closes  around  the  tooth ;  so  that,  when  the  oper- 
ation is  completed,  this  part  may  be  protected  from 
particles  of  food.  When  the  necks  of  the  teeth  are  kept 
separate  as  in  nature,  and  the  gum  is  in  normal  condition, 
it  protects  the  portion  of  enamal,  and  covers  the  well- 
inserted  and  finely-finished  gold  beneath  its  margins  so 
perfectly  that  solution  of  the  basis-substance  of  the  tissue 
of  the  part,  and  even  its  discoloration,  is  prevented.  This 
protection  of  the  parts  continues,  unless  in  after-years  there 
be  diminished  circulation  in  the  capillaries  and  lack  of 
nutrition  to  the  gum,  and  it  commences  to  return  to 
embryonal  corpuscles.  Decay  may  then  take  place  at  the 
necks  of  the  teeth,  though,  at  the  age  when  there  is 
usually  loss  of  molecular  tone  and  recession  and  loosening 
of  the  gum-tissue,  there  follows  deposition  of  lime-salts 
under  or  about  the  margins  of  the  gums.  This  deposit 
may  incite  pericementitis,  and  the  result  may  be  the 
breaking  of  the  fine  line  of  living  matter  between  the 
epithelial  and  other  bodies  of  the  part,  and  prevention  of 
the  rebuilding  of  the  tissue.  When  the  gum  is  in  normal 
condition,  it  is  so  close  to  the  necks  of  the  teeth  as  to  pre- 
vent lodgment  of  foreign  matter  beneath  its  margins. 

The  gum  fills  the  space  between  the  teeth  almost  entirely, 
and  protects  the  parts  it  covers,  and  this  tissue  should 
always  be  guarded  by  full  restoration  of  the  contour  of 
the  missing  enamel.  The  gold  ought  to  be  finely  finished 
at   all  points,  that  there  may  be  no  obstruction  to  the 


108  NOTES    ON    OPERATIVE    DENTISTRY. 

tissue  again  closing  around  the  neck  of  the  tooth  operated 
upon.  In  this  manner  the  margin  of  enamel  at  or  near 
the-  neck  of  the  tooth  against  which  the  gold  is  placed 
and  smoothly  finished  is  protected  by  the  gum,  and,  if  the 
whole  operation  has  been  properly  performed,  extension 
of  decay  at  that  point  is  prevented. 

In  cases  where  calcification  is  imperfect,  and  solution 
of  the  lime-salts  of  the  teeth  takes  place  rapidly,  it  is  well 
to  keep  cavities  of  decay  filled  with  gutta-percha  or  oxy- 
chloride  of  zinc  until  there  is  more  complete  deposition 
of  lime-salts  in  the  basis-substance  of  the  enamel  and 
dentine.  If  a  permanent  operation  be  performed  with 
gold  before  perfect  calcification  takes  place,  it  is  necessary 
to  free  the  edges  of  enamel  and  to  keep  the  margins  from 
contact  by  full  and  complete  restoration  of  the  contour  of 
the  missing  tissue. 

All  the  better  grades  of  white  gutta-percha  are  com- 
posed mainly  of  the  simple  so-called  red  gutta-percha  and 
oxide  of  zinc.  More  depends  upon  the  preparation  than 
upon  the  component  parts  of  the  material,  so  that  care 
must  be  taken  in  its  manufacture. 

Three  grades  of  white  gutta-percha  are  prepared, — the 
"  low  heat,"  the  "  medium,"  and  the  "  high  heat."  The 
"  medium,"  which  becomes  sufiiciently  plastic  at  a  tem- 
perature of  about  200°  F.,  is  the  best  grade  for  general 
use.  The  gutta-percha  should  be  softened  on  a  porcelain 
or  metal  plate  over  hot  water,  and  with  some  prepara- 
tions of  gutta-percha  even  of  proper  grade  the  water  must 
be  raised  to  the  boiling-point  to  make  the  material  soft 
enough  to  be  worked  nicely.  The  instruments  for  pack- 
ing and  the  fiattened  burnisher  for  trimming  gutta-percha 
had  best  be  heated  on  a  metal  plate,  although  careful 
heating  over  the  flame  of  alcohol  will  answer  the  purpose. 


NOTES    ON    OPERATIVE    DENTISTRY. 


109 


The  instruments  ought  to  be  warmer  than  the  material 
that  is  being  used. 

Instruments  for  packing  gutta-percha  should  be  of  such 
shape  as  to  reach  all  parts  of  cavities,  Fig.  4y. 

and  be  medium  or  rather  large- 
pointed,  and  tinely  serrated  (Fig.  49). 
The  cavity  should  be  kept  dry  with 
the  rubber  dam,  and  the  gutta-perchii 
ought  to  be  made  to  adhere  to  the 
dentine  and  enamel.  The  whole 
cavity  must  be  filled  by  carefully 
adding  one  small  piece  to  another. 
In  trimming  a  gutta-percha  filling 
the  flat  burnisher  ought  always  to 
be  pressed  toward  the  margin  of  the  cavity,  thus  avoid- 
ing the  loosening  of  any  of  the  material  from  the  edges 

Fig.  50. 


of  enamel.     After  this  is  done  the  surface  of  the  gutta- 
percha should  be  nicely  finished  with  linen  tape  and  small 


110  NOTES    ON    OPERATIVE    DENTISTRY. 


Fig.  51. 
/ 


pellets  of  Japanese  bibulous  paper  saturated  with 
chloroform. 

In  using  oxjehloride  or  oxyphosphate  of  zinc 
place  a  little  of  the  fluid  upon  a  porcelain  palette 
(Fig.  50)  or  a  piece  of  glass,  and  put  sufficient  of 
the  oxide  of  zinc  for  the  case  for  which  it  is  to 
be  used  near  the  fluid,  and,  when  all  is  in  readi- 
ness for  the  insertion  of  the  material,  the  powder 
should  be  worked  into  the  liquid  with  a  small 
spatula  (Fig.  51).  Sufficient  powder  should  be 
added  to  and  mixed  with  the  liquid  to  make 
a  thick,  creamy  mass,  when  it  must  be  carefully 
placed  in  the  cavity  at  once,  and  gently  pressed 
against  every  part  of  the  dentine  with  small  pellets 
of  cotton.  Oxyphosphate  of  zinc  usually  sets  so 
quickly  that  it  requires  more  rapid  manipulation 
than  the  oxychloride. 

In  most  cases,  after  the  preparation  of  cavities, 
particularly  those  that  are  deep,  carbolic  acid 
ought  to  be  applied,  not  only  to  serve  as  a  disin- 
fectant, but  to  coagulate  the  protoplasm  of  the 
ends  of  the  fibers  in  the  dentinal  canaliculi  and 
partially  obtund  sensation.  In  those  cases  where 
thermal  changes  may  produce  more  than  the 
usual  shock  in  healthy  tissue  after  the  gold  has 
been  inserted  or  the  operation  completed,  oxy- 
chloride of  zinc  ought  to  be  placed  in  the  bottom 
of  the  cavity  as  a  non-conductor  of  the  currents 
incited  by  heat  and  cold  in  the  dentinal  fibers. 


RESTORATION  OF  CONTOUR,  AND  PREVEN- 
TION OF  EXTENSION  OF  DECAY. 


"VTT'HEX  a  cavity  within  the  approximal  wall  of  a 
'  '  bicuspid  or  molar  has  been  prepared  as  described, 
a  starting-point  {a,  Fig.  36)  should  be  made  in  some  part 
of  the  cervical  wall,  usually  toward  the  palatal  or  lingual 
surface,  and  in  that  portion  of  the  dentine  between  it  and 
the  enamel  or  cementum  which  shall  be  the  safest.  This 
point  in  which  to  start  the  filling  should  be  only  deep 
enough  to  retain  the  narrow  pieces  of  cohesive  foil  first 
inserted  while  other  pieces  are  being  built  upon  them, 
and  the  filling  carried  along  to  the  groove  in  each  wall  of 
the  cavity.  The  operator  must  always  be  careful  to  have 
a  piece  of  foil  or  some  of  the  gold  between  the  Berrations 
or  end  of  the  packing-instrument  and  the  enamel  or 
dentine.  The  gold  ought  then  to  be  built  against  every 
portion  of  the  dentine,  and  packed  as  perfectly  as  possible 
along  the  enamel  and  a  little  beyond  its  margins,  and 
carried  fully  to  the  line  that  originally  defined  the  contour 
of  the  part.  To  thus  perform  an  operation  it  is  nec- 
essary to  build  that  part  of  the  gold  nearest  to  the  buccal 
and  masticating  surfaces  against  the  approximal  surface 
of  the  tooth  adjoining.  By  performing  this  operation 
with  the  electro-magnetic  mallet,  the  passing  of  the 
packing  instrument  from  off  the  edge  against  or  over 
which  the  gold  is  being  placed  may  not  only  be  avoided, 
but  the   surplus   material   can   be   so  cut   away  during 

111 


112 


NOTES    ON    OPERATIVE   DENTISTRY. 


the  performance^of  the  operation  that  comparatively  little 
Fig.  52.*  trimming  is  af- 

terwards neces- 
sary.    Cohesive 
gold    foil,    1^0. 
30,  40,  or  60  for 
large,     or     foil 
folded    to    No. 
16  or  IsTo.  20  for 
smaller  fillings, 
and  which    has 
not  been  in  con- 
tact    with     the 
fingers,  but  pre- 
pared  and   ma- 
nipulated  as 
hereinbefore  de- 
scribed,  ought 
to   be    used    in 
the   performance   of    all   operations.     The    gold 
should  be  made  compact  with  the  electro-mag- 
netic mallet,  especially  in  the  case  just  referred 
to,  and  where  frail  edges  of  enamel  are  to  be  sup- 
ported and  protected. 

When  foil  has  been  so  built  in  place  that  the 
substitution  for  lost  tissue  is  complete,,  a  fine,, 
broad  saw,  or  a  suitable  thin  file  (Fig.  52)  should 
be  used  to  cut  away  the  surplus  material  to  the 
prepared  edge  of  enamel  against  which  the  gold 
is  placed,  and  to  aid  in  shaping  the  filling  like  the 
original  contour  of  the  part ;  after  which  narrow 
strips  (a  line  or  an  eighth  of  an  inch  wide),  cut 


*Fig.  52  shows  a  fine  saw  and  some  suitable  files  for  trim- 
rninj;  and  shaping  gold  fillings. 


NOTES    ON    OPERATIVE    DENTISTRY.  113 

from  tine  emery-cloth  or  emory-paper,  should  be  so 
manipulated  as  to  properly  tinish  the  surface  of  the  gold. 
When  this  has  been  done,  the  rubber  dam  should  be  re- 
moved, and  the  finishing  completed  by  the  use  of  tine 
pumice  and  silex  on  linen  tape.  The  gold  at  the  masti- 
cating surface  should  be  trimmed  down  with  tine  burs, 
and  made  concave,  or  finished  to  represent  the  original 
contour  or  outline  of  the  part  operated  upon.  The  gold 
should  be  so  placed  in  the  cavity  as  to  be  flush  A\ith  the 
prepared  margins  of  enamel,  and  made  concave  when  such 
concavity  is  indicated.  Fine  burs,  rather  than  corundum 
cones,  should"  be  used  for  trimming  and  shaping  such  fill- 
ings, as  well  as  those  in  the  palatal  surfaces  of  the  incisors 
and  cuspids,  because  the  form  of  the  remaining  part  or 
parts  of  the  cusps  and  prepared  edges  of  enamel  against 
which  the  gold  is  placed  may  be  changed  or  disfigured, 
and  the  teeth  made  less  useful  if  finished  with  corundum 
points.  The  polishing  of  the  gold  upon  the  surfaces  re- 
ferred to  should  be  done  with  pumice  and  silex  upon  suit- 
ably-shaped points  of  wood,  rubber,  or  leather. 

Restoration  of  the  contour  of  a  part  or  parts  of  the 
crown  of  a  tooth  signifies  not  only  the  building-out  and 
finishing  of  the  gold  to  the  line  that  defined  the  figure 
originally,  but  by  it  is  meant  the  knuckling-up  of  the 
tooth  restored  to  the  one  adjoining  in  such  manner  that 
the  margins  of  enamel  shall  be  free -from  contact,  and 
that  food  cannot  be  forced  between  the  teeth  from  the 
masticating  surface. 

For  full  restoration  of  contour  it  is  necessary  to  gain 
space  to  prepare  the  cavity,  pack  the  gold,  and  finish  the 
filling.  This  must  be  done  either  by  wedging  at  the  time 
of  performing  the  operation,  or  by  pre\dously  placing  or 
pressing  wood,  linen  tape,  or  cotton  between  the  teeth  as 
before  described.  8 


114  NOTES  ON  OPERATIVE  DENTISTRY. 

In  eveiy  case  the  gold  ought  to  be  built  out  to  the 
original  contour  of  the  part  and  a  little  beyond  the  mar- 
gins; then  finished  down  to  the  surface  of  the  enamel, 
so  that  the  outline  of  the  whole  filling  shall  be  the  same 
as  the  line  that  defined  the  contour  of  the  lost  tissue : 
— contour  signifying  "the  line  that  bounds,  defines,  or  ter- 
^iG-  53.  minates   a   figure "    (Fig. 

53).  This  line  ought  al- 
ways to  be  fully  restored, 
particularly  on  the  ap- 
proximal  surfaces  of  bi- 
cuspids and  molars,  and 
the  gold  should  be  care- 
fully  trimmed  down  to  and 
finely  finished  flush  with  the  margins  of  enamel,  which 
margins,  in  these  cases  more  especially  than  in  others, 
must  be  free  from  the  tooth  adjoining,  to  prevent  extension 
Fig  54  *  ^^  decay  (Fig.  54,  a,  b).  When  operations 
have  been  so  performed  as  to  entirely  pre- 
vent fluids  from  entering  between  the 
gold  and  the  tissue  against  which  it  is 
"W:  placed,  and  all  discoloration  has  been  re- 
/..  \  -  -  moved  fi-om  the  surface  of  the  remaining 
tissue,  the  gold  tint  may  be  seen  through 
the  light  walls  or  edges  of  the  translucent  enamel  soon 
after  the  removal  of  the  rubber  dam  and  completion  of 
the  operation.  If  there  is  a  dark  line  or  spot  at  a  part 
where  the  gold  should  be  against  the  dentine  and  enamel, 
the  operation  has  been  imperfectly  performed,  and,  if  not 
re-performed,  as  it  ought  to  be,  there  follows  extension  of 
decay  and  failure  of  the  filling.  If  gold  is  not  placed 
compactly  against  and   is   not  flush  with  the  edges  of 

*  Fig.  54  shows  restoration  of  contour  and  (a,  b,)  free  edges  of  enamel. 


u 


NOTES    ON    OPERATIVE    DENTISTRY.  115 

enamel,  the  operation  is  not  such  as  is  demanded  for  the  pre- 
servation of  the  remaining  tissue.  A  flat  surface  of  gold 
should  not  be  made,  because  the  tooth  thus  operated 
upon  and  the  one  adjoining  may  move  closer  together, 
and  solution  of  enamel  will  then  take  place  at  or  near  the 
part  or  parts  in  contact.  In  such  cases  solution  of  the 
lime-salts  usually  takes  place  near  the  buccal,  palatal,  or 
lingual  wall  of  enamel  that  is  in  contact  along  the  ap- 
proximal  surface  against  which  gold  (or  other  material 
used)  has  been  placed,  while  other  parts  around  the  same 
filling  may  remain  free  fi-om  decay.  Decay  about  fillings 
is  not  likely  to  take  place  where  there  is  full  restora- 
tion of  the  contour  of  the  missing  tissue  and  such  close 
knuckling-up  of  the  teeth  as  to  leave  the  margins  of 
enamel  free  from  contact  and  prevent  the  wedging  of 
food  between  the  approximal  surfaces  that  are  restored. 
Restoration  of  contour  prevents  contact  of  the  margins 
of  enamel,  and  this  prevention  is  necessary  for  the  pre- 
servation of  the  remaining  tissue,  especially  when  the 
tissues  (the  enamel  and  dentine)  of  the  tooth  operated 
upon  are  not  fully  calcified.  In  many  of  these  cases, 
where  about  the  space  of  half  a  bicuspid  remains  because 
of  the  extraction  of  a  tooth,  and  fillings  are  required 
within  the  approximal  walls  of  the  molar  or  bicuspid  ad- 
joining, the  contour  should  be  carried  beyond  the  original 
line  far  enough  to  entirely  close  the  space  referred  to, — 
thus  increasing  the  surface  for  and  aiding  mastication,  as 
well  as  giving  needed  support  to  the  teeth  remaining 
in  the  arch  such  as  they  originally  had.  The  contour  of 
missing  tissue  ought  always  to  be  so  restored  wnth  gold 
that  the  enamel  of  one  organ  may  not  be  in  contact  with 
that  of  the  next  in  the  arch,  and  that  a  part  of  the  gold 
in  the  one  may  be  against  or  tightly  knuckled-up  to  the 


116  NOTES  ON  OPERATIVE  DENTISTRY. 

normal  tissue  of  the  tootli  adjoining,  or  to  a  filling,  if 
one  lias  been  inserted  in  it  (Fig.  54).  Then  comfort  in 
mastication  is  assured  and  solution  is  not  likely  to  take 
place,  because  the  free  margins  of  enamel  against  which 
the  gold  has  been  placed  will  be  washed  by  the  fluids 
taken  into  the  mouth  as  well  as  be  cleansed  by  the  saliva, 
which  is  kept  in  almost  constant  motion  by  the  action  of 
the  tongue,  lips,  and  cheeks. 

Dr.  H.  C.  Longnecker,  of  Philadelphia,  Pa.,  writing 
upon  this  subject,  fairly  states,  in  the  following  paragraph, 
whatever  there  is  to  be  considered  as  objections  to  the 
operations  just  described,  viz. :  "  The  labor,  skill,  expense, 
and  time  required  for  this  method  of  operating  will,  I 
think,  be  admitted  by  all ;  but  while  these  may  be  and 
doubtless  are  practical  objections,  they  in  no  manner 
impair  the  correctness  of  the  principle.  These  operations 
represent  the  ideal,  the  poetry  of  dentistry;  they  are 
useful;  they  are  beautiful.  Let  us  guard  the  beautiful 
with  reverent  care  ;  the  useful  will  take  care  of  itself." 

When  operations  have  been  performed  in  the  manner 
herein  described,  and  the  fillings  are  as  finely  finished  as 
suggested,  they  are  the  best  for  the  protection  of  the 
enamel  against  or  over  which  the  gold  is  placed,  and  for 
the  prevention  of  the  wedging  of  food  against  the  gums 
and  their  consequent  recession.  They  subserve  well  the 
purpose  of  mastication,  and  present  a  beautiful  appear- 
ance, and  this  is  the  only  way  to  keep  the  margins  of 
enamel  of  the  approximal  surfaces  of  tlie  teeth  perma- 
nently separated, — fully  restore  the  contour  of  the  tissue 
that  is  lost. 


SUMMARY  OF  PRINCIPLES  RELATING  TO 
FILLING  TEETH. 


npHE   following   ten   articles   are  given   as   indicating 
-*-      some  of  the  principles  which  ought  to  guide  all 
operators  in  the  filling  of  teeth  : 

I.  Gold,  'properly  used,  is  the  best  known  material  for 
the  permanent  preservation  of  the  teeth. 

II.  With  restoration  of  contour  so  complete  as  to  keep 
the  margins  of  enamel  free  fi'om  contact  with  the  tooth 
adjoining,  extension  of  decay  is  prevented. 

III.  "  Failure  in  operations  is  mainly  due  "  to  the  gold 
not  being  packed  closely  against  the  dentine  and  enamel 
at  every  part,  thus  allowing  fluids  to  enter  at  such  parts 
and  further  decay  to  take  place.  The  failure  of  a  filling, 
therefore,  is  "  mainly  due  "  to  the  mcmnpafibility  of  the 
operator  with  his  work. 

lA'".  A  cavity  that  can  be  "  satisfactorily  filled  with 
anything  is  worth  filling  "  with  gold.  The  contour  of  any 
tooth  can  be  restored  with  gold  if  the  operator  has  the 
ability  to  properly  apply  the  rubber-dam  and  perform  the 
operation. 

V.  Skillful  operators  first  see  that  the  parts  are  in 
healthy  condition,  and  then  so  perform  operations  with 
gold  as  to  prevent  further  decay,  or  they  fill  with  oxy- 
chloride  of  zinc  to  avoid  shock  from  changes  of  tempera- 
ture and  cover  with  gold. 

VI.  A  ^Wing-material  "  may  be  the  best  that  is  known 

117 


118  NOTES    ON    OPERATIVE    DENTISTRY. 

for  the  tooth,  and  yet  leak  badh/,"  because  of  "  defective 
manipulation;"  but  to  save  the  tooth  that  best  material, 
gold,  must  be  so  inserted  as  to  prevent  leakage. 

YII.  "  Gutta-percha,  -properly  used,''  is  a  good  filling- 
material,  but  it  serves  a  temporary  purpose  only,  except 
where  there  is  no  friction  from  mastication,  from  the 
free  use  of  brush  and  powder,  or  from  floss-silk,  when 
it  may  prevent  decay  for  several  years. 

YJH.  "  A  good  gutta-percha  filling,  in  its  jwojper  i^lace, 
is  better  than  a  poor  gold  one,"  and  better  than  any  other 
material  inserted  in  a  careless  and  imperfect  manner. 

IX.  The  excellence  of  "  amalgam,  _^:>e?^  se,"  consists  only 
•  in  enabling  an  operator  to  fill  a  cavity  with  it  where  he 

might  otherwise  resort  to  extraction.  [Amalgam  shrinks, 
and  fluids  penetrate  between  it  and  the  enamel,  which  be- 
comes fractured  little  by  little;  oxidation  takes  place,  and, 
while  slightly  retarding  decay,  the  oxide  discolors  tissue, 
especially  the  dentine  in  the  teeth  of  young  persons,  and 
the  filling  presents  an  unsightly  appearance.] 

X.  "  The  use  of  '  plastic '  filling-materials  "  does  not 
tend  to  the  exercise  of  that  care  and  the  development 
of  that  skill  which  are  necessary  for  the  successful  practice 
of  "  that  dentistry  which  has  for  its  standard  of  excellence 
'  ability  to  make '  good  '  gold  fillings.'  "  An  operator  with 
such  ability  can  not  only  perform  operations  with  gold  so 
as  to  ".sai-e  teeth"  but  he  can  insert  any  other  material 
better  than  one  who  has  not  the  "  ability  to  make  gold 
fillings." 


COVERING  AND  PROTECTING  FRAIL  AVAILS 
OF  ENAMEL  WITH  GOLD. 


"TTTHERE  frail  edges  of  enamel  are  to  be  supported 
^  '  and  protected,  the  margins  should  be  slightly 
beveled,  so  that  the  tissue  may  be  the  better  kept  in  place 
by  the  gold,  which  should  be  evenly  finished,  to  present  a 
fine  appearance  when  the  operation  is  completed. 

Should  a  crown  present  a  dark  appearance,  owing  to 
the  discoloring  of  the  protoplasm  in  the  fibers  throughout 
the  dentinal  canaliculi  and  the  net-work  of  living  matter 
in  the  basis-substance,  efforts  should  be  made  at  bleaching 
with  chloride  of  lime  and  acetic  acid ;  but  the  appearance 
may  be  improved  only  temporarily.  Previous  to  the  use 
of  such  ao-ents,  the  foramen  should  be  closed  with  g-old 
and  part  of  the  pulp-chamber  securely  filled,  and  as  much 
dentine  removed  as  can  be  afforded  without  making;  the 
crown  too  frail.  The  method  of  packing  the  cavity  full 
of  alum,  and  saturating  this  with  "  Labarraque's  solution 
of  chlorinated  soda,"  may  be  employed.  The  bleaching 
is  supposed  to  be  produced  by  the  action  of  free  chlorine 
upon  the  discolored  protoplasm  in  the  fibers  of  the  dentine. 
Oxychloride  of  zinc  may  serve  the  purpose  of  giving 
nearly  the  proper  shade  or  tint  through  the  enamel ;  but 
this  may  not  add  the  necessary  strength  to  the  tissue, 
which  must  be  supported  and  protected  when  the  dentine 
is  removed.  To  restore  the  shade  of  a  crown  approxi- 
mately, it  may  be  necessary  to  remove  all  the  dentine  from 

119 


120  NOTES    ON   OPERATIVE   DENTISTRY. 

the  cutting-edge  to  the  neck  of  the  tooth,  with  the  excep- 
tion of  a  thin  layer  about  the  line  of  junction  of  the 
enamel  and  cementum.  The  cutting-edge  of  the  labial 
wall  of  enamel  must  in  many  cases  be  cut  off  and  slightly 
beveled  outwardly  with  a  corundum  wheel,  and  evenly 
and  finely  finished  -svith  fine  emery-cloth,  so  that  it  will 
line  with  the  edges  of  the  other  teeth,  when  the  re- 
maining tissue  is  protected  by  a  covering  of  gold  of  a  fall 
thirty-second  or  even  the  sixteenth  of  an  inch  in  thick- 
ness, and  the  cutting-edges  present  an  even  line  or  edge 
to  the  sight.  The  mesial  and  distal  edges,  as  well  as  the 
cutting-edge  of  enamel,  must  be  evenly  and  smoothly 
finished  with  strips  of  emery-cloth,  Xo.  ^  and  No.  0.  (A 
case  prepared  as  described  and  ready  for  the  gold  is  here  il- 
lustrated. Fig.  55.)  The  discolored  dentine,  extending  some 
ri«-  -J-J-  distance  into  the  root,  must  be 

cut  away;  all  foreign  particles 
should  be  removed,  and  thepulp- 
'  jl  chamber  somewhat  enlarged 
^^-  with  a  Gates  drill  to  the  apical 
foramen,  which  should  then  be  closed  with  gold  and  the 
operation  of  restoring  the  contour  of  the  crown  com- 
menced. The  gold  in  that  part  of  the  pulp-chamber  not 
directly  in  sight  ought  to  be  inserted  by  the  aid  ^of  a 
hand-mallet,  and  all  the  rest  made  compact  with  the 
electro-magnetic  mallet.  The  packing-instrument  must 
be  ver}"  carefully  operated  upon  the  foil  placed  against 
the  inner  portion  and  the  edge  of  the  labial  wall  of 
enamel.  Cohesive  gold,  No.  4,  folded  to  No.  16  or  20, 
ought  to  be  placed  against  the  wall  of  enamel,  and  No. 
30  gold  built  into  the  body  of  the  crown.  The  whole  of 
such  an  operation  can  be  performed  without  fracturing 
the  enamel.     When  completed  properly,  these  operations 


NOTES    ON    OPERATIVE    DENTISTRY.  121 

not  only  support  and  protect  the  tissue  airainst  and  over 
the  edges  of  which  the  gold  has  been  placed,  but  the 
delicate  gold-tint  is  seen  through  the  translucent  enamel, 
even  though  there  may  have  been  marked  discoloration 
before  the  operation  was  commenced. 

The  following  description  of  a  clinic  operation  per- 
formed by  the  author  before  the  First  District  Dental 
Society  of  ^ew  York,  February  7,  1882,  illustrates  both 
extensive  restoration  of  contour  and  the  binding  in  and 
protection  of  the  parts  of  the  tooth  remaining : 

This  operation  was  performed  on  the  left  upper  second 
molar,  a  pulpless  tooth  with  the  whole  anterior  approx- 
imal  and  a  good  portion  of  the  masticating  surface  miss- 
ing, all  the  other  teeth  on  that  side  of  the  mouth  being  in 
position.  There  had  been  such  treatment  as  was  necessary 
to  allay  pericementitis,  and  all  obstruction  to  return  of  the 
surrounding  tissues  to  normal  condition  was  removed. 
The  decomposed  pulp-tissue  had  been  taken  out  of  the 
roots  of  the  molar,  and  each  root  had  been  temporarily  filled 
with  cotton,  and  the  cavity  of  decay  with  gutta-percha, 
some  nionths  before.  The  opening  in  each  buccal  root 
had  been  very  carefully  followed  up  and  slightly  enlarged 
with  a  delicate  Gates  drill.  At  this  clinic,  after  the  rub- 
ber-dam had  been  applied,  narrow  strips  of  light  gold  foil 
were  carefully  placed  in  each  root,  from  the  apical  foramen 
to  the  large  or  bulbous  portion  of  the  pulp-  ^lo-  -"^^ 
chamber,  which  was  then  filled  with  oxy- 
chloride  of  zinc — Agate  cement.  A  piece  of 
light-medium  rubber-dam,  about  eight  inches 
square,  was  selected,  and  five  holes  were  cut  in  it,  two  of 
them  a  little  larger  than  the  others,  for  the  first  and  second 
molars.  With  the  Delos  Palmer  clamp,  "  L.  S.,  7 " 
(Fig.  56),  applied  to  the  second  molar — the  "  left  superior 


122  NOTES    ON    OPERATIVE    DENTISTRY. 

seventh  "  tooth  from  the  median  line — the  rubber  dam  was 
stretched  over  clamp  and  tooth,  and  brought  forward  over 
the  first  molar,  each  bicuspid,  and  the  cuspid, — these  being 
the  five  teeth  for  which  the  holes  were  made.  A  ligature 
of  waxed  floss-silk  was  then  placed  in  position  and  tied  at 
the  neck  of  the  first  molar  and  that  of  the  cuspid.  This 
having  been  done  (the  operator  doing  all  of  it  alone  in 
less  than  five  minutes),  the  edges  of  the  rubber  were 
carefully  folded  and  held  out  of  the  way  with  a  rubber-dam 
holder,  and  the  patient  made  more  comfortable  by  the 
placing  of  a  fine  napkin  under  the  rubber  next  to  the  lips, 
chin,  and  cheeks.  All  was  now  ready  for  the  operation, 
and  the  parts  were  quite  accessible  as  well  as  dry.  While 
the  cement  in  the  bulbous  portion  of  the  pulp-chamber 
was  hardening,  the  preparation  of  the  cavity  was  com- 
pleted and  suflicient  anchorage  for  the  filling  made ;  the 
margins  of  the  cavity  Avere  cut  even  and  smooth;  the 
cusps  were  taken  off"  almost  an  eighth  of  an  inch,  and 
the  whole  of  each  remaining  wall — buccal,  palatal,  and 
posterior  approximal — was  otherwise  trimmed,  slightly 
beveled,  and  prepared  for  the  gold  with  corundum  wheels. 
When  the  cavity  was  thus  prepared,  and  a  good  medium- 
sized  starting-point  had  been  made  in  the  dentine  in  line 
with  the  palatal  root  at  the  edge  of  the  cement,  the 
filling  was  commenced  and  the  grooves  were  filled  with 
Xo.  30  foil.  Most  of  the  operation  was  carried  forward 
with  No.  60  gold,  each  piece  of  foil  used  being  passed 
over  the  flame  of  an  alcohol  lamp, — making  it  as  cohesive 
as  possible, — and  placed  in  the  cavity  by  an  assistant. 
The  gold  was  put  in  place  and  made  compact  with  the 
electro-magnetic  mallet  attached  to  a  freshly-charged  four- 
cell  Bunsen  battery,  after  the  starting-point  and  a  por- 
tion of  each  groove  had  been  tilled,  and  as  the  narrow 


NOTES    ON    OPERATIVE    DENTISTRY.  123 

stripsof  foil  were  placed  along  the  cervical  wall  and  put  com- 
pactly and  safely  in  position  over  all  the  margins,  the 
surplus  material  was  trimmed  away  from  the  edges  where- 
ever  trimming  was  required,  without  puncturing  the 
rubber-dam.  The  whole  operation  was  carried  steadily 
forward  with  but  little  labor  till  the  contour  was  fally 
restored,  including  the  covering  of  the  buccal,  palatal, 
and  posterior  edges  of  the  crown  to  the  depth  of  almost 
an  eighth  of  an  inch,  and  the  building  down  of  each  cusp 
^vith  gold  in  one  solid  mass.  Over  two  books  of  one-eighth 
of  an  ounce  each,  or  about  one  hundred  and  twenty-eight 
grains  of  gold,  were  used  in  the  filling,  and  the  insertion 
of  the  same  and  the  restoration  of  the  contour,  including 
the  trimming  away  of  the  surplus  material  and  the  shap- 
ing of  the  crown  with  the  electro-magnetic  mallet,  as  the 
work  was  progressing,  required  about  two  hours  and  ten 
minutes.  This  operation  did  not  cause  pericementitis, 
though  the  pressure  of  the  ligature  and  the  clamp  induced 
slight  inflammation  of  the  lower  part  of  the  pericementum 
and  gum  surrounding  the  neck  of  the  tooth. 


PLACING  CROWNS  ON  ROOTS  OF  TEETH. 


OHOULD  solution  of  the  lime-salts  of  the  enamel  and 
'^  dentine  not  be  prevented  or  arrested,  little  by  little 
the  tissues  become  fractured  and  their  contour  broken  up ; 
the  death  of  the  pulp  takes  place;  the  crown  is  soon 
gone,  and  the  edges  of  enamel  yet  remaining  scarcely 
rise  above  the  surrounding  soft  tissue.  Even  when  a  case 
presents  with  here  and  there  a  crownless  root,  treatment 
such  as  is  herein  mentioned  should  be  commenced  and 
continued  until  the  remaining  tissues  are  in  normal  con- 
dition; after  which,  all  operations  that  may  be  required 
ought  to  be  performed  as  perfectly  as  possible,  and  arti- 
ficial crowns  placed  upon  the  roots — especially  those  of 
the  incisors,  cuspids,  and  first  bicuspids. 

Where  fracture  of  enamel  has  been  extensive,  and  its 
contour  is  almost  or  entirely  broken  up,  it  is  not  only 
necessary  to  carefully  prepare  the  root  for  the  placing  of 
an  artificial  crown  upon  it,  but,  as  in  all  operations  upon 
pulpless  teeth  or  roots,  special  care  must  be  taken  that 
inflammation  of  the  pericementum  is  not  induced. 

Preparatory  to  mounting  a  crown  in  the  manner  now 
to  be  described,  the  root  should  be  cut  beyond  the  mar- 
gin of  the  gum  and  a  plain  "  pivot-tooth  "  placed  upon  it 
by  means  of  a  wood  pivot  surrounded  with  white  gutta- 
percha, which,  when  made  plastic  by  heat  and  the  crown 
inserted,  protrudes  and  presses  the  gum  away  from  the 
margin  of  the  root.  After  this  temporary  crown  has 
124 


NOTES    ON    OPERATIVE    DENTISTRY.  125 

been  in  place  a  few  days  (or  perhaps  only  for  a  day 
or  two)  a  gold  wire,  No.  12  or  13,  should  be  accu- 
rately fitted  in  and  placed  as  far  up  the  root  as  possi- 
ble. A  gold  plate,  No.  26  (18-k.),  should  be  fitted  to  the 
prepared  surface  of  the  root,  and  an  opening  made  in  it 
just  large  enough  for  the  wire  to  pass  through.  The 
plate  and  wire  should  be  placed  in  position  and  the  latter 
marked  with  the  point  of  a  knife  or  lancet-blade,  so  that, 
when  the  wire  is  put  into  a  suitable  hole  made  in  char- 
coal and  the  plate  placed  upon  it,  there  shall  be  no  diffi- 
culty in  deciding  just  where  to  solder  the  parts  together. 
When  thus  fitted,  soldered,  and  then  annealed,  the  gold 
wire  and  plate  should  again  be  placed  in  position  and 
more  accurately  fitted  to  the  root.  There  should  be  no 
movement  of  the  metal  while  the  edges  of  the  plate  are 
being  fitted  to  the  prepared  surface  of  the  root  by  the  aid 
of  the  mallet.  After  this  is  done  the  ^^^re  should  be  cut 
off"  to  within  about  two  lines  of  the  outer  surface  of  the 
plate,  and  the  edge  of  the  latter  so  trimmed  as  to  be  on  a 
line  with  the  circumference  of  the  root,  and  then,  with 
wire  and  plate  in  position,  an  impression  of  the  parts 
should  be  taken  in  plaster  of  Paris.  An  ^^^-  57. 
illustration  of  a  wire  and  plate,  after  having 
been  fitted  as  described,  is  here  given  (Fig. 
57,  a).  When  this  is  done  and  the  vdre  and 
plate  taken  from  the  root  and  put  in  place 
in  the  impression,  a  correct  model  of  the 
teeth  and  parts  adjoining  can  be  made,  with  the  gold  in 
the  same  relative  position  as  when  in  the  mouth.  After 
the  model  is  made,  the  gold  removed  from  it,  the  end  of 
the  wire  which  extended  outside  the  root  to  aid  in  mark- 
ing the  position  of  the  wire  and  plate  in  the  impression 
cut  off"  and  filed  down  to  the  surface  of  the  plate,  a  thick, 


126  NOTES    ON    OPERATIVE    DENTISTRY. 

narrow  gold  backing  should  be  fitted  and  riveted  to  a 
suitable  crown  (plain  "  plate-tooth  "  with  "  straight  pins") 
and  a  groove  cut  along  each  side,  and  in  some  cases  near 
the  cutting-edge  of  the  porcelain,  as  illustrated  in  Figs. 
57,  b  and  59,  b.  This  is  done  in  order  that  the  parts  may 
then  be  built  out  and  the  porcelain  more  perfectly  se- 
cured, and  the  contour  of  the  palatal  portion  restored 
with  pure  gold,  as  shown  in  the  cut  with  crown  in  place 
Fig.  58.  (Fig.  58).      After  the   backing 

is  placed  upon  the  porcelain  it 
should  be  attached  to  the  plate 
with  wax,  and  the  whole  care- 
fully removed  from  the  model, 
incased  in  plaster  and  sand,  gradually  heated,  and  sol- 
dered. The  porcelain  ought  then  to  be  examined  with  a 
magnifying-glass,  so  that  the  operator  may  thus  determine 
whether  any  fracture  has  taken  place  during  the  heating 
and  soldering.  The  parts,  prepared  as  described  and 
illustrated,  may  be  held  by  screwing  the  wire  in  a  hand- 
vise  while  the  gold  foil  is  being  built  in  place.  The  gold 
foil  should  not  only  be  built  into  the  grooves  and  made 
compact  throughout,  but  the  cutting-edge  (or  cusps,  if 
the  crown  be  a  bicuspid),  after  being  slightly  beveled, 
ought  to  be  covered  with  solid  gold  as  a  protection  from 
the  occlusion  of  the  lower  teeth.  The  narrow  line  of 
gold  need  not  be  made  conspicuous,  if  it  be  visible  at  all. 
This  can  be  nicely  done  with  the  electro-magnetic  mallet, 
and  the  crown  made  ready  for  insertion  by  the  time  of 
the  next  appointment  with  the  patient. 

A  very  good  and  less  difficult  method  of  preparing 
crowns  is  to  back  the  whole  of  the  porcelain  and  restore 
the  contour  of  the  palatal  portion  with  fine  gold  plate 
(18-  to  22-k.),  united  with  correspondingly  fine  solder. 


NOTES  ON  OPERATIVE  DENTISTRY.  127 

The  apical  foramen  should  be  closed  with  gold.  If 
gutta-percha  or  oxychloride  of  zinc  be  used  for  this  pur- 
pose, some  of  the  material  may  be  pressed  through  the 
foramen,  but  with  gold  the  operation  can  be  made  more 
certain  and  satisfactory.  To  avoid  any  exposure  of  gold, 
should  recession  of  the  gum  take  place,  the  edge  of  the 
plate  ought  to  be  so  cut  away  that  the  porcelain  may  be 
accurately  fitted  upon  the  labial  portion  of  the  root. 

When  all  is  in  readiness  for  placing  the  crown  upon 
the  root,  fine  barbs  should  be  made  with  a  knife  or  lancet 
along  the  entire  surface  of  the  gold  wire,  and  a  thin  layer 
of  white  gutta-percha  (such  as  requires  little  heat)  placed 
around  the  wire  and  against  the  plate ;  the  metallic  parts 
should  be  heated  sufiiciently  to  just  soften  the  gutta- 
percha, and,  with  the  root  dried,  the  whole  must  be  im- 
mediately pressed  and  carefully  hand-malleted  to  place. 
The  surplus  stopping  should  be  trimmed  ofi*  with  a  lancet 
a  few  hours  or  the  day  after  the  crown  is  placed  upon  the 
root,  or  when  the  gutta-percha  shall  be  thoroughly  cooled. 
The  gum  will  then  have  been  so  pressed  away  that  the 
boundary-line  between  the  crown  and  root  can  be  seen, 
and  the  edge  of  the  gutta-percha  smoothly  finished  with 
pellets  of  Japanese  bibulous  paper,  lint,  or  cotton,  satu- 
rated with  chloroform. 

There  is  a  still  less  difiicult  and  yet  good  method  of 
placing  crowns  upon  roots  of  teeth,  and  one,  too,  that 
does  not  require  so  much  time  as  that  just  described;  but 
the  root  should  be  prepared  and  a  gold  wire  fitted  in  it  in 
the  same  manner.  A  suitable  plain  "pivot"  crown, 
having  a  hole  in  it  a  little  larger  than  the  gold  wire, 
should  be  selected  and  fitted  to  the  surface  of  the  root  as 
perfectly  as  possible,  and  the  opening  in  the  porcelain 
filled  ^vith  fine,  well-seasoned  hickory-wood,  which  must 


128 


NOTES    ON   OPERATIVE   DENTISTRY. 


then  be  cut  off"  even  with  the  base  of  the  crown,  and  a 
hole  drilled  in  the  center  and  entirely  through  it  large 
enough  to  insert  one  end  of  the  wire.  The  surface  of 
the  wire  should  be  roughened  or  finely  barbed  along  its 
whole  length,  and  one  end  placed  (not  malleted)  tightly 
in  the  opening  made  for  it  in  the  wood  in  the  crown,  the 
whole  being  then  placed  upon  the  root  and  finished  as 
above  described. 

An  artificial  crown,  by  whatever  method  mounted,  can 
be  more  successfully  placed  upon  a  root,  and  all  opera^ 
tions  better  performed,  when  the  rubber-dam  is  applied 
than  where  it  is  not  used,  and  it  should  therefore  be 
secured,  if  the  operator  can  apply  it,  to  the  adjoining 
teeth  and  then  to  the  root  before  the  final  fitting  and 
mounting  of  the  crown. 

Building  crowns  of  gold  upon  roots  of  teeth  and  facing 
them  with  porcelain  makes  the  most  secure  and  satisfac- 
tory operation,  though  difiacult. 
After  preparing  the  root,  clos- 
ing the  foramen  with  gold, 
and  cutting  away  the  irregular 
or  projecting  edges  to  within 
about  a  half-line  of  the  margin 
of  the  gum  (which  is  left  to  aid 
in  applying  the  rubber-dam),  a 
gold  wire,  Xo.  18  or  14,  with  a  fine,  sharp  thread  cut  upon 
it,  should  be  accurately  fitted  in  the  pulp-chamber  to  near 
the  apical  foramen.  To  the  platinum  pins  of  the  porce- 
lain selected  for  the  case  a  cylinder  or  tube  made  of  gold 
plate  should  be  fitted,  and,  after  it  is  opened  (Fig,  59,  a), 
riveted,  and  then  closed,  it  should  be  placed  in  plaster  and 
fine  sand,  and  carefully  heated  and  soldered,  A  thread 
must  then  be  cut  in  the  cylinder  corresponding  to  that 


NOTES    ON    OPERATIVE    DENTISTRY.  129 

upon  the  wire  to  which  it  is  to  be  attached.  This  is  done 
in  order  that  the  crown  may  l)e  more  securely  attached 
to  the  root  than  by  the  method  described  by  the 
writer  in  the  Dental  Cosmos,  June,  1873.  The  end  of  the 
gold  tube  next  to  the  cutting-edge  of  the  crown  may  be 
beveled  and  a  slot  made  in  the  wire  at  that  point,  so  that 
the  cylinder  shall  be  prevented  from  turning;  while  still 
greater  strength  is  added  by  impacting  gold  into  the  open 
part,  thus  spreading  the  slotted  end  of  the  wire.  A  groove 
should  be  cut  with  a  corundum  disk  in  each  side  (6),  and 
sometimes  along  the  cutting-edge  of  the  porcelain,  into 
which  gold  foil  is  to  be  placed,  to  secure  greater  strength 
and  permanency. 

When  all  is  in  readiness  for  the  operation,  the  rubber- 
dam  should  be  applied  to  two  teeth  on  each  side  of  the  root 
and  to  the  root  itself.     The  ligature  of  waxed  floss-silk 
should  be  placed  twice  around  the  root,  and  tightened  and 
pressed  well  to  place  with  a  burnisher;  the  ends  of  the 
silk  wrapped  twice,  as  in  tying  a  surgeon's  knot,  and  the 
ligature  then  attached  to  the  ring  at  the  end  of  an  elastic 
rubber-dam  holder  and  held  iust  below  the  eds:e  of  the 
slightly  upraised  lip,  so  that,  when  the  holder  is  fixed  to 
a  tie  put  around  the  patient's  neck,  there  shall  be  con- 
stant tension   upon   the   ligature.     After  this  has  been 
done  the  root  should  be  trimmed  down  with  corundum 
wheels    or   cones    to   the   ligature,   although    not    close 
enough  to  displace  it.    The  porcelain  should  then  be  so 
fitted  as  to  leave  a  half-line  of  space  to  be  filled  with  gold 
(as  at  c)  between  it  and  the  root  after  the  wire  has  been 
placed  in  the  cylinder    and    screwed    into  the  root.     In 
placing  the  parts  in  position  a  little  oxychloride  of  zinc, 
of  nearly  the  consistence  of  cream,  should  be  placed  in 
the  root  next  to  the  gold  that  closes  the  foramen,  and  the 

9 


130  NOTES    ON    OPERATIVE    DENTISTRY. 

gold  wire  at  once  put  iii  this  and  screwed  securely  to 
place.  After  the  oxychloride  of  zinc  has  crystallized, 
sufficient  of  it  and  of  the  dentine  should  be  cut  away 
with  small  burs  to  secure  good  anchorage  for  the  gold 
now  to  be  placed  as  perfectly  and  solidly  as  possible 
around  the  wire,  to  and  over  the  margin  of  the  root, 
along  the  gold  tube,  into  the  grooves  made  in"  the  porce- 
lain, and  between  it  and  the  labial  margin  of  the  root  (c). 
While  the  gold  is  being  placed  around  the  wire  in  the 
root,  the  porcelain  can  be  turned  a  little  to  one  side  upon 
the  gold  wire  till  the  cylinder  is  reached  and  restoration 
of  the  contour  of  the  parts  commenced.  All  the  gold 
should  be  cohesive  and  impacted  by  the  aid  of  the  elec- 
tro-magnetic mallet,  with  which  the  surplus  foil  can  easily 
be  trimmed  away  from  the  margin  of  the  root  as  placed 
upon  it,  and  the  form  of  the  crown  so  nicely  carried  for- 
ward that  but  little  dressing  is  afterwards  necessary. 
The  gold  should  be  filed  even  with  the  margin  of  the 
root,  and  finished  with  narrow  strips  of  fine  emery-cloth 
at  and  near  the  point,  while  the  rubl)er-dam  is  yet  in 
place.  After  this  is  removed  the  gold  should  be  so  cut 
away  as  to  allow  proper  occlusion  of  the  teeth,  and  a  little 
space  should  be  gained  by  very  careful  wedging  for  trim- 
ming and  finishing  the  gold  in  the  manner  before  described 
along  each  approximal  surface  separately. 

In  placing  crowns  upon  roots  of  second  bicuspids  and 
molars,  it  may  be  wellto  insert  a  suitable  gold  wire,  with 
a  fine,  sharp  thread  cut  upon  it,  and  to  build  around 
over  the  same,  and  restore  the  entire  contour  of  the 
crown  with  gold  foil;  but  a  better,  if  not  a  stronger, 
operation  can  be  made  by  filling  the  pulp-chamber,  as 
well  as  the  entire  crown,  with  cohesive  gold,  and  using 
the  mallet.     Such  operations  are  not  so  difficult  as  those 


NOTES   ON    OPERATIVE    DENTISTRY. 


131 


where  gold  crowns  are  faced  with  porcelain,  nor  do 
they  require  so  much  time.  In  some  cases  two  books 
of  No.  30  or  60  gold  (should  so  much  be  required) 
can  be  carefully  impacted  and  the  crown  properly  formed 
in  about  two  or  two  and  a  half  hours,  with  the  aid  of  the 
electro-magnetic  mallet  and  an  assistant  to  pass  the  nar- 
row pieces  over  the  flame  of  alcohol  and  to  place. 

Among  the  cases  presented  at  the  clinic  given  under 
the  auspices  of  the  First  District  Dental  Society  of  New 
York,  in  April,  1881,  was  one  where  it  had  been  said  to 
be  impossible  to  apply  the  rubber-dam  to  the  remaining 
part  of  a  molar.  The  buccal  wall  alone  was  standing, 
and   the   fracture  extended   three-sixteenths  of  an  inch 


Fig.  60. 


Fig.  01. 


above   the   margin   of    the   gum    and    alongside 

the  palatal  root,  and  in  order  to  get  a  clamp  and 

the   rubber-dam  on  this   part  of   the  tooth,  the 

gum  had  to  be  pressed  away  some  distance  %vith 

gutta-percha.     In  operating  upon  this  case  at  that 

clinic  the  author  demonstrated  what  can  be  done 

in  overcoming  difliculties  in  applying  the  rubber-dam  for 

the  performance  of  extensive  and  difficult  operations  with 

gold. 

The  crown,  as  prepared  for  the  restoration  of  its  con- 
tour with  gold,  is  here  illustrated  (Fig.  60);  the  buccal 


132  NOTES    ON    OPERATIVE    DENTISTRY. 

wall  having  been  cut  oft'  an  eighth  of  an  inch  (see  Fig. 
61),  to  be  covered  and  bound  in  with  foil.  A  gold  wire 
was  fitted  in  the  palatal  root,  and  another  in  one  of  the 
buccal  roots  (Fig.  60).  These  were  soldered  together,  and 
a  hook  was  made  on  one  part  of  the  wire  (Fig.  62), 
which  was  carefully  fitted  to  a  depression  cut  to  corres- 
pond with  it  in  the  dentine  of  the  palatal  root  along  one 
side  of  the  somewhat  enlarged  pulp-chamber.  When  the 
wire  was  put  in  place,  the  hook  was  pressed  toward  the 
depression,  so  that,  in  order  to  come  away,  it  would  have 
to  bring  with  it  nearly  all  the  dentine  between  the  depres- 
sion and  the  surface  of  the  root.  The  other  wire  was 
barbed,  and,  though  it  did  not  fit  very  tightly  before  the 
barbing,  the  use  of  a  hand-mallet  was  necessary  to  put 
it  in  position.  The  apical  foramen  of  each  root  was 
closed  with  narrow  strips  of  light  gold  foil.  After  this 
preliminary  work  had  been  done,  and  when  the  larger 
part  of  the  operation  was  to  be  performed,  a  Delos  Palmer 
clamp,  "  R.  S.,  8  "  (Fig.  63),  was  placed  on  the  third  molar, 
^^'^^-  ^''■'-  and  a  Tees  "  festooned  "  clamp  (Fig.  64)  on 
the  remaining  part  of  the  second  molar. 
The  rubber-dam  was  then  stretched  over 
each  clamp  separately,  and  put  on  the  second 
bicuspid,  the  rubber  bridging  over  the  space 
left  by  the  loss  of  the  first  molar.  The 
clamps  and  rubber-dam  were  applied  in 
about  three  minutes. 

After  the  clamps  and  rubber-dam  had 
been  adjusted  and  the  parts  had  dried,  and  the  final  prep- 
aration had  been  made,  oxychloride  of  zinc  was  placed 
in  each  root,  and,  while  the  cement  was  yet  plastic,  the 
two  united  wires  were  driven  to  the  place  to  which  they 
had  been  fitted  (Fig.  60).    When  the  cement  had  hardened 


NOTES    ON    OPERATIVE    DENTISTRY.  133 

surticiently,  it  was  cut  away  from  all  parts  where  foil 
could  be  placed  advantageously  and  made  to  strengthen 
the  operation.  The  contour  of  the  entire  crown  was  then 
fully  restored  with  gold.  This  operation  took  one  hun- 
dred and  fifty  grains,  or  two  and  a  half  books,  of  gold — 
cohesive  foil,  Nos.  30  and  (principally)  60.  With  the 
assistance  of  friends,  who  annealed  and  placed  each  piece 
of  foil  in  the  cavity  ready  for  packing,  it  was  all  made 
compact,  and  the  crown  and  cusps  were  restored  and  put 
in  proper  shape,  with  the  electro-magnetic  mallet,  in  four 
hours. 

This  operation  was  performed  without  inciting  perice- 
mentitis, although  the  pressure  of  the  clamp,  being  kept 
in  place  so  long  and  held  so  far  up  on  the  tooth,  brought 
about  some  inflammation  of  the  pericementum  and  the 
gum  surrounding  the  neck  of  the  tooth.  This,  however, 
soon  passed  away. 


ATTACHING  CROWNS  TO  TEETH  WHERE 
ROOTS  ARE  MISSING. 


"TTTHERE  tooth  and  root  are  both  missing,  a  porcelain 
'  ^  face  can  be  successfully  built  into  one  or  both  of 
the  adjoining  teeth,  with  gold  attachments.  The  insertion 
of  a  crown  without  plate  or  clasps  is  a  difficult  operation, 
but  when  well  performed,  if  the  crown  is  attached  to 
teeth  that  are  firm  in  their  sockets,  it  is  both  satisfactory 
and  permanent. 

The  principal  beneficial  results  gained  by  the  building- 
in  of  crowns  under  such  circumstances  are,  the  longer 
preservation  of  the  remaining  teeth  and  the  gums  and 
alveolar  process  in  normal  condition;  the  prevention  of 
the  absorption  of  the  hard  as  well  as  the  soft  tissues  under 
and  because  of  the  pressure  of  plates, — the  loosening  and 
loss  of  teeth  from  this  cause  sometimes  occurring  years 
before  there  would  be  solution  of  the  lime-salts  of  the 
maxillary  border  and  recession  of  the  gums.  To  secure 
sufficient  anchorage  for  the  insertion  of  a  crown,  it  may 
sometimes  be  necessary  to  destroy  a  pulp  ;  but  this  ought 
to  be  the  last  resort,  and  should  be  done  only  when  calci- 
fication of  the  enamel  and  dentine  is  complete  or  ap- 
parently BO.  The  end,  if  well  attained,  justifies  the 
means,  mainly  because  the  normal  condition  of  the  re- 
maining teeth,  the  gums,  and  the  alveolar  process  is 
better  maintained  than  when  a  plate  is  worn. 

The  first  report  given  of  the  attachment  of  a  crown  to 
134 


NOTES    ON    OPERATIVE   DENTISTRY.  135 

natural  teeth,  without  plate  or  clasp,  appeared  in  the  Den- 
tal Coffmos  for  October,  1869.  In  this  article  it  was 
stated  that  Dr.  B.  J.  Bing,  of"  I'aris,  had  inserted  several 
crowns  in  this  manner,  some  of  which  had  then  been  in 
place  nearly  a  year.  Dr.  Bing  backs  a  porcelain  crown 
with  18-carat  gold  plate,  and  to  this,  for  the  insertion  of 
crowns  of  the  central  and  lateral  incisors,  he  usually 
solders  a  gold  wire,  each  end  of  which  he  builds  with 
gold  into  a  cavity  newly  made,  or  into  one  caused  by 
decay  in  the  palatal  portion  of  the  enamel  of  each  of  the 
two  teeth  adjoining, — in  some  cases,  also,  extending  and 
building  a  small  gold  plate  or  wire  into  a  cavity  in  each 
approximal  surface  next  to  the  space  to  be  filled. 

The  first  operation  of  attaching  a  crown  to  adjoining 
teeth  to  fill  the  space  of  a  missing  tooth  and  root  by  the 
author  was  performed  February  12,  1873,  in  the  follow- 
ing manner :  After  suitably  forming  the  cavities  in  the 
approximal  wall  of  each  tooth  next  to  the  space  left  by 
the  one  that  had  been  extracted  (unnecessarily)  some  years 
before,  an  impression  of  the  parts  was  taken  in  plaster  of 
Paris,  and  a  plain  porcelain  crown  was  selected,  fitted  to 
place,  and  backed  with  18-carat  gold  plate.  A  portion 
of  the  backing  extended  about  one  and  a  half  lines  from 
each  side  of  the  crown  for  insertion  in  the  cavities  pre- 
pared in  the  adjoining  teeth,  and  to  these  a  gold  wire 
was  soldered  to  fit  into  the  pulp-chamber  of  the  central 
and  lateral  incisors.  A  small  gold  plate  was  then  formed 
to  fit  upon  the  gum,  covering  it  to  the  extent  of  the  space 
occupied  by  the  neck  of  the  natui'al  tooth.  When  the 
backing  was  riveted  to  the  pins  in  the  porcelain  and 
placed  in  position,  and  while  the  whole  rested  on  the 
small  plate  upon  the  gum,  the  backing  and  plate  were  so 
secured  by  wax  that  they  could  be  removed  intact,  and, 


136  NOTES    ON    OPERATIVE    DENTISTRY. 

after  being  placed  in  a  matrix,  soldered.  Each  extended 
side  of  the  backing  and  the  surface  of  the  wire  was  barbed 
with  an  engraver's  lossing-tool,  so  that  the  gold  foil 
when  filled  into  every  part  would  the  better  secure  the 
crown. 

The  porcelain,  with  the  gold  attachments,  being  ready 
for  insertion,  a  piece  of  light-medium  rubber-dam  was  put 
in  place  on  two  teeth  on  each  side  of  the  space  to  be  filled, 
and  over  the  gum  upon  which  the  crown  was  to  rest. 
(The  rubber  takes  up  but  little  space,  and  this  is  more 
than  compensated  for  when  the  ligature  of  waxed  floss- 
silk  is  pressed  to  or  near  the  neck  of  each  adjoining  tooth.) 
Oxychloride  of  zinc  was  then  placed  in  the  pulp-chamber 
of  the  central  and  lateral  incisors  and  the  crown  was  at  once 
pressed  to  place.  "When  the  cement  had  hardened  suf- 
ficiently to  safely  admit  of  further  progress  in  the  work, 
a  portion  of  it  was  cut  away  from  around  the  wire  so 
as  to  make  proper  anchorage  for  the  gold.  Small  pieces 
of  light  cohesive  gold  foil  were  then  impacted  around 
part  of  the  wire  and  that  portion  of  the  plate  extending 
into  the  cavities,  and  the  crown  was  thus  secured.  The 
porcelain  and  gold  attachments  as  prepared  for  insertion 
Fi«-  65.  and  the  crown  in 

position  are  here  il- 
lustrated (Fig.  65). 
The  cavity  in  the 
central  incisor  was 
then  extended  to 
the  cutting-edge  of 
the  tooth,  so  that  access  might  be  had  to  the  wire  and  both 
sides  of  the  plate.  Foil  could  not  otherwise  have  been 
put  in  place,  unless  a  portion  of  the  labial  margin  of 
enamel  had  been  cut  away,  and  this  would  have  been 


NOTES    ON    OPERATIVE    DENTISTRY.  137 

objectionable  because  of  the  exposure  of  gold.  A  small 
part  of  the  labial  instead  of  the  cutting-edge  of  the  enamel 
of  the  lateral  was  removed,  for  the  reason  that  there  is  not 
such  a  body  of  tissue  in  a  lateral  as  to  safely  allow  it  to  be 
cut  away  to  the  same  extent  as  in  a  central  incisor.  The 
margin  of  enamel  was  so  formed,  and  the  foil  so  inserted 
and  finished,  however,  that,  though  the  gold  could  be  seen, 
it  was  not  conspicuous. 

While  the  operation  just  described  proved  successful, 
— remaining  firmly  fixed  in  place  till  the  death  of  the 
patient,  nine  years  after  the  crown  was  inserted, — there  is 
a  possibility  in  such  cases  of  the  porcelain  being  broken 
from  the  platinum  pins  which  hold  it  to  the  gold  plate. 

The  method  followed  by  the  author  in  cases  of  this 
character  since  performing  his  first  operation  is  quite  dif- 
ferent from  the  mode  adopted  in  the  case  just  described, 
which  was  executed  somewhat  according  to  Dr.  Bing's 
plan,  and,  though  the  work  is  more  diificult,  yet  the  im- 
proved crown  is  stronger,  and  more  complete,  cleanly,  and 
beautiful  than  when  gold  plate  is  simply  riveted  and  sol- 
dered to  the  porcelain.  It  was  to  avoid  such  an  accident 
as  the  breaking  of  the  porcelain  from  the  pins  that  the 
author  modified  the  method  of  preparing  and  inserting 
crowns.  Among  the  changes  introduced  were  those  of 
cutting  a  groove  (though  not  too  deeply)  in  each  side 
and  along  the  cutting-edge  of  the  porcelain,  and  placing 
gold  foil  solidly  in  the  grooves  and  slightly  over  the  cut- 
ting-edge, to  make  the  porcelain  more  secure  than  when 
the  platinum  pins  alone  hold  it,  and  to  protect  the  edge 
from  the  occlusion  of  the  lower  teeth ;  also,  to  build  the 
attachments  of  the  crown  into  the  approximal  surfaces 
only  of  the  adjoining  teeth. 

The  necessities  of  the  case  may  require  that  a  groove 


138  NOTES    ON    OPERATIVE    DENTISTRY. 

shall  be  cut  with  a  disk  across  the  porcelain  between 
the  pins,  in  which  the  wire  to  connect  the  artificial 
crown  with  the  natural  teeth  is  to  be  placed,  either  under 
the  plate  or  so  that  the  edges  of  the  latter  may  be  joined 
to  it. 

A  starting-point  should  be  made,  either  between  the 
gold  backing  and  the  porcelain  or  between  this  and  the 
wire,  and  the  latter  should  be  firmly  fixed  in  a  hand-vise 
while  the  gold  foil  is  being  put  in  place  and  made  compact 
with  the  electro-magnetic  mallet.  The  greater  part  of 
the  preparation  of  a  crown  which  remains  to  be  made,  and 
the  whole  of  the  building  of  gold  foil  about  it,  is  done 
out  of  the  mouth,  at  whatever  time  may  best  suit  the 
operator.  The  work  requires  care,  and  must  be  skillfully 
and  well  done.  When  t]^e  gold  is  properly  and  solidly 
placed  in  the  grooves  and  over  the  backing  and  wire,  it 
not  only  aids  in  securing  the  porcelain,  but  the  contour 
Fig.  66.  of   the    crown    can    be    nicely 

filled  out  (Fig.  66)  and  the 
operation  made  durable  and 
beautiful. 

The  surface  of  the  gold  placed 
along  the  base  of  the  crown  to  the  edge  of  the  porcelain, 
which  is  to  rest  against  the  gum,  together  with  the  palatal 
portion,  ought  to  be  properly  formed  and  finished  before 
the  crown  is  put  in  place,  in  the  manner  before  described. 
There  should  be  a  little  space  between  the  wire  and  the 
cervical  wall  in  each  tooth  to  which  the  crown  is  to  be 
attached,  and  narrow  pieces  of  light  cohesive  gold  foil 
should  be  carefully  placed  in  this  space  between  the  wire 
and  the  enamel  with  small  suitably-curved  instruments, 
and  afterwards  solidified  with  the  mallet.  The  surface  of 
the  gold  at  this  part,  at  least,  should  be  smoothly  finished, 


NOTES    ON    OPERATIVE    DENTISTRY.  139 

with   narrow  (one-sixteenth   inch)    strips  of  fine  emery- 
cloth,  before  the  rubber-dam  is  removed. 

In  cases  where  the  pulp  is  living  in  one  or  both  of  the 
teeth  to  which  an  artificial  crown  is  to  be  attached,  the 
heavy  gold  plate  or  the  wire  must  be  so  arranged  as  to 
fit  as  accurately  and  be  made  as  secure  as  possible  in 
the  cavities  prepared  for  them.  In  some  cases,  where 
the  form  of  the  cavity  admits  of  it,  it  is  well  to  adjust 
and  solder  a  small  gold  plate  to  the  end  of  and  at  right 
angles  with  the  wire  attached  to  the  crown.  This  plate 
should  be  so  formed  and  beveled  that  gold  foil  can  be 
solidly  built  over  the  surface  of  it  next  to  the  artificial 
crown  and  into  the  groove  made  around  the  cavity  in  the 
dentine  along  the  boundary-line  between  this  tissue  and 
the  enamel.  When  all  is  in  readiness  for  the  operation, 
oxychloride  of  zinc  should  be  placed  in  each  cavity  and 
the  crown  immediately  put  in  place,  and  very  carefully 
held  there  till  the  cement  has  so  crystallized  as  to  securely 
hold  the  ends  of  the  wire  and  the  plates.  About  an  hour 
is  necessary  for  such  perfect  crystallization  as  to  safely 
admit  of  the  preparation  for  and  the  packing  of  the  gold 
foil.  The  oxychloride  of  zinc  should  be  left  between  the 
little  plate,  or  end  of  the  wire,  and  the  bottom  of  the 
cavity,  not  only  because  it  fills  all  parts  where  gold  can- 
not well  be  placed,  but  because  the  preparation  also  pro- 
tects the  dentinal  fibers  from  thermal  changes. 

The  crown  devised  by  Dr.  I.  F.  Wardwell,  of  Kew 
York,  and  as  built  in  by  him,  aifords  an  excellent  plan 
for  the  insertion  of  crowns  where  the  pulp  is  living  in 
each  tooth  adjoining,  and  is  the  best  of  the  various 
methods  or  modifications  yet  mentioned  herein  that  have 
been  practiced  by  the  few  who  have  attached  crowns  to 
teeth   without   plate  or  clasp.     His  plan  consists  in  so 


140 


NOTES    ON    OPERATIVE   DENTISTRY. 


arranging  and  soldering  a  thick,  narrow  gold  plate  to  the 
platinum  pins  in  the  porcelain  crown,  and  so  beveling  the 
sides  of  the  plate  towards  it  as  to  have  this  plate  slide 
tightly  into  another  gold  plate  shaped  to  receive  it  (Fig. 
67,  A,  b).     This  second  gold  plate  is  soldered  to  the  gold 

Fia.  67. 


Fig.  68. 


A- — 


IZB3 


wire  (Fig.  68),  which  is  built  into  cavities  (Fig.  67,  c)  in 
the  adjoining  teeth  with  gold  foil,  and,  by  inclosing  the 
beveled  sides  of  the  plate  on  the  porcelain,  "dove-tails" 
or   holds   the    crown   in    position.     The    crown   is   then 

pressed  into  place  and  made  se- 
cure by  filling  in  gold  foil  near 
the  cutting-edge  of  the  tooth,  after 
the  wire,  with  the  plate  soldered 
to  it,  is  built  into  place. 

One  of  the  most  satisfactory 
operations  the  author  ever  per- 
formed was  the  insertion  of  a 
crown  where  the  root  of  a  cuspid 
had  been  extracted,  on  which  accountthe  lady  had  been  sub- 
jected to  the  wearing  of  a  gold  plate  for  some  time.  The 
crown  was  prepared  and  the  contour  filled  out  with  foil 
as  described  and  illustrated  (Fig.  i]6),  and  gold  wire, 
IS^o.  13,  was  attached  to  and  built  in  with  the  porcelain, 
and  fitted  in  the  pulp-chamber  of  the  adjoining  lateral 
incisor.  This  same  wire  extended  from  the  anterior  to 
near  the  posterior  approximal  surface  of  the  first  bicuspid, 


Enlarged  view  of  gold  staple 
and  wire,  to  be  soldered  together 
afthe  line  A,  B  ;  C,  D,  grooves 
cut  around  the  three-sided  wire. 


NOTES   ON   OPERATIVE    DENTISTRY.  141 

the  pulp  of  which  was  in  normal  condition.  When  the 
crown  was  ready  for  insertion,  it  was  placed  and  held  in 
position  with  oxychloride  of  zinc,  and  cohesive  gold  foil 
was  then  carefully  packed  around  the  exposed  portion  of 
the  wire  in  the  root  and  made  compact  with  the  electro- 
magnetic mallet,  as  was  also  that  placed  in  the  cavity 
in  the  crown  of  the  incisor  and  in  the  cavity  in  each 
approximal  wall  of  the  bicuspid,  as  well  as  around  and 
over  the  wire,  joining  the  two  fillings  in  this  tooth 
through  the  enlarged  fissure.  All  crowns  should  be  pre- 
pared and  finished  in  the  manner  described,  with  such 
change  or  additional  work  as  is  necessary  to  jjlace  them 
on  roots,  or  to  attach  them  to  single  or  the  two  adjoining 
teeth  where  roots  are  missing. 

Methods  have  been  devised  and  adopted  with  the  object 
of  lessening  the  time  necessary  to  perform  these  (as  well' 
as  other)  operations,  and  making  them  simple,  easy,  and 
cheap  by  the  use  of  amalgam  or  other  plastic  filling- 
materials;  but,  in  addition  to  the  excellent  judgment  and 
ability  required,  sufiicient  time  must  be  taken,  and  the 
use  of  gold  is  necessary  for  the  doing  of  really  fine, 
beautiful,  and  permanent  work. 

When  a  crown  is  to  be  attached  to  one  tooth  alone,  the 
operation  is  not  likely  to  be  successful  (except  where  a 
bicuspid  crown  is  built  into  a  molar)  unless  the  tooth 
which  is  to  support  the  crown  is  pulpless,  and  then  such 
an  operation  can  be  made  both  durable  and  beautiful. 

When  it  is  decided  to  build  into  one  tooth  only,  a 
gold  wire,  no  lighter  than  jS'o.  12,  should  be  used.  It 
ought  to  be  fitted  as  far  up  the  root  as  it  is  safe  to  enlarge 
the  pulp-chamber  for  it,  but  the  drilling  may  properly  be 
done  only  after  every  part  of  the  pulp  has  been  removed 
and  the  apical  foramen  has  been  carefully  closed  with 


142  NOTES    ON    OPERATIVE    DENTISTRY. 

small,  narrow  pieces  of  light  gold  foil,  which  must  not  be 
put  in  place  so  long  as  there  is  any  irritation  about  the 
end  of  the  root. 

In  the  case  here  illustrated  (Fig.  69)  the  wire  is  fitted 
in  the  root  and  bent  to  receive  the  crown.     The  cavity  is 
YiQ.  09.  prepared  for   the   fillirig-in   of 

gold.  The  cuspid  (as  well  as 
the  other  teeth  remaining  in 
the  mouth)  became  so  abraded 
as  to  expose  the  dentine,  so 
that  the  margins  of  enamel 
had  to  be  prepared  for  the 
placing  of  gold  over  them,  and,  when  the  crown  was 
built  into  place,  they  were  carefully  covered  with  and  are 
thus  protected  by  the  solid  metal.  After  the  porcelain 
part  of  the  crown  of  the  lateral  incisor  had  been  fitted 
to  the  model  and  soldered  to  the  wire  (shown  in  Fig.  69, 
— this  portion  of  the  wire  should  be  flattened  somewhat  in 
some  cases),  the  groove  was  made  around  the  porcelain, 
the  foil  was  solidly  built  in  place,  and  finished  in  the 
manner  hereinbefore  described,  and  the  crown  was  then 
inserted  and  the  contour  of  the  cuspid  restored  with 
ij:old.  (The  root  of  the  left  central  incisor  remains,  and 
the  crown  which  is  fitted  upon  it  is  prepared  for  the 
building  on  of  gold  foil.*) 

When  the  lateral  incisor  crown,  in  the  case  illustrated, 
was  ready  for  insertion,  and  the  gold  at  the  base,  which 
was  to  rest  upon  the  gum,  had  been  nicely  fitted  to  it,  and 
the  whole  of  the  gold  was  smoothly  finished,  a  good-sized 
piece  of  light-medium  rubber-dam  was  applied  to  the  teeth 
(the  cuspid  and  the  central  and  lateral  incisors)  on  each 
side  of  the  space  to  be  filled,  and  so  arranged  as  to  cover 

*The  outline  of  tlie  groove  is  not  distinctly  shown  in  the  cut  (Fig.  69). 


NOTES  ON  OPERATIVE  DENTISTRY,  143 

the  gum  and  the  root  between  these  teeth.  The  crown 
was  made  to  so  test  upon  the  gum  as  to  press  the  blood 
from  the  capillaries  of  the  part,  and  thus  prevent  particles 
of  food  from  getting  under  it.  While  the  thickness  of  the 
rubber-dam  might,  to  some  slight  extent,  prevent  the 
placing  of  such  a  crown  against  the  gum  as  firmly  as 
it  should  be  pressed,  yet  this  thickness  is  compensated 
for  by  the  pressing-up  of  the  gum  when  the  floss-silk 
ligatures  are  placed  about  the  neck  of  each  adjoining 
tooth.  After  all  this  had  been  done,  fine  barbs  were  cut 
around  the  gold  wire  with  a  sharp  knife-blade,  oxy- 
chloride  of  zinc  was  placed  in  the  pulp-chamber  of  the 
cuspid,  and,  while  the  cement  was  still  plastic,  the  crown 
was  at  once  pressed  to  place,  and  for  a  few  moments  held 
there. 

After  the  oxychloride  of  zinc  had  hardened  sufiiciently 
to  safely  admit  of  it,  the  cement  was  cut  away  from 
around  the  wire  at  such  parts  as  would  make  proper 
anchorage  for  the  gold.  There  was,  and  in  every  such  case 
there  should  be,  a  little  space  left  between  the  wire  and  the 
cervical  wall,  to  be  filled  v^ith  gold  for  the  protection  of  the 
enamel  at  this  part.  l!^arrow  pieces  of  light  cohesive  foil 
were  first  placed  in  this  space  with  small,  suitably-curved 
instruments,  and  afterwards  solidified  with  the  mallet; 
after  which  a  little  larger  and  heavier  (none  over  I^o. 
32),  though  still  narrow,  pieces  of  folded  foil  were  used 
for  placing  around  and  about  the  wire  in  the  root,  filling 
the  cavity,  restoring  the  contour,  and  covering  and  pro- 
tecting the  prepared  margins  of  enamel.  The  pieces  of 
gold  were  made  thoroughly  cohesive,  and  wefe  compacted 
with  the  electro-magnetic  mallet.  The  surface  of  the  gold 
placed  around  the  wire,  between  it  and  the  cervical  wall, 
as   well   as   all  that  part   near  the  gum,  was  smoothly 


144  NOTES    ON    OPERATIVE    DENTISTRY. 

finished  with  small  files  and  very  narrow  (one-sixteenth 
inch  wide)  strips  of  emery-cloth  before  the  removal  of  the 
rubber-dam ;  after  which  the  remainder  of  the  gold  was 
made  smooth  and  so  trimmed  down  as  to  make  sure  of  the 
proper  occlusion  of  the  teeth.  The  crown  attached  to  the 
cuspid  was  made  just  short  enough  to  be  free  from  the 
striking  of  the  lower  teeth.  The  operation  was  finished 
at  another  time  with  Hindostan  stones,  together  with 
pumice  upon  fine  wood  made  into  suitable  shape. 

When  a  crown  can  be  securely  attached  to  one  instead 
of  two  teeth,  the  time  of  building-in  the  same  is  lessened 
about  one  half.  The  slight  movement  which  takes  place 
in  the  socket  of  the  tooth  supporting  the  crown  is  not 
interfered  with  by  the  gold  wire  holding  the  porcelain, 
as  when  two  teeth  are  fijsed  together.  If  it  should  after- 
wards become  necessary  to  perform  operations  upon  the 
adjoining  teeth,  the  rubber-dam  can  be  applied  as  readily 
as  before  attaching  the  crown. 

The  most  extensive  operation  of  attaching  a  crown  to 
the  two  adjoining  teeth  by  the  author  was  performed 
before  the  Pennsylvania  State  Dental  Society,  at  Dela- 
ware Water  Gap,  in  July,  1879.  In  this  case  solution  of 
enamel  had  taken  place  in  many  of  the  teeth,  and  cavities 
of  decay  had  been  prepared  and  filled  from  time  to  time. 
The  enamel  was  abraded  and  the  dentine  exposed  along 
the  entire  cutting-edge  of  each  tooth  that  occluded  ^vith 
another.  The  right  upper  lateral  incisor  had  been  lost 
twelve  years  before.  The  crown  of  the  left  cuspid  was 
missing,  and  but  a  small  portion  of  the  enamel  and  dentine 
of  the  first  bicuspid  upon  either  side  remained.  These  last 
were  pulpless,  as  were  also  the  right  cuspid  and  central 
and  left  lateral  incisors,  and  the  pulp-chamber  of  each  of 
these  had  been  filled.     All  the  operations  made  necessary 


NOTES    ON    OPERATIVE    DENTISTKY. 


145 


by  the  abrasion  and  fracture  of  the  enamel  from  time  to 
time,  and  because  of  imperfections  in  the  fillings  pre- 
viously inserted,  were  performed  before  the  insertion  of 
the  crown  in  the  space  left  by  the  loss  of  the  lateral 
incisor.  After  this  crown  had  been  adjusted,  and  each 
cavity  and  pulp-chamber  had  been  prepared  for  the  gold, 
the  case  appeared  as  here  illustrated  (Fig.  70). 

Fig.  70. 


The  apical  foramen  of  each  pulpless  tooth  was  closed, 
and  the  whole  of  each  pulp-chamber  in  which  a  wire 
was  not  placed  was  filled  with  gold.  A  gold  screw  was 
placed  in  the  pulp-chamber  and  extended  into  the  crown 
of  each  bicuspid  (Fig.  70).*  The  pulp-chamber  of  the  left 
cuspid  was  so  shaped  with  burs  as  to  make  sure  and  cer- 
tain anchorage  for  the  cohesive  gold  foil  placed  in  it,  and 
for  the  permanent  support  of  the  entire  gold  crown.  The 
crown  of  this  tooth  was  not  faced  with  porcelain,  because 
the  teeth  of  the  gentleman  for  whom   these  operations 

*The  cut  (Fig.  70)  illustrates  the  case  very  well,  though  there  are 
parts  and  grooves  in  which  to  anchor  the  gold  that  are  not  distinctly 
shown. 

10 


146  NOTES  ON  OPERATIVE  DENTISTRY. 

were  performed  were  but  slightly  exposed  to  view;  and 
then,  too,  the  gold  had  to  be  placed  over  the  cutting- 
edges  of  the  incisors,  the  cuspid,  and  bicuspids,  to  protect 
them  from  the  occlusion  of  the  lower  teeth  and  restore 
them  to  near  their  former  length. 

The  contour  of  each  crown  was  restored  with  cohesive 
gold,  made  compact  with  a  well-adjusted  electro-magnetic 
mallet,  guided  carefully,  and  operated  with  the  power 
of  a  freshly-charged  four-cell  Bunsen  battery.  The  foil 
was  placed  over  the  finely  prepared  edges  of  enamel,  the 
gold  was  made  as  solid  throughout  as  possible,  and  the 
margins  were  not  marred  in  the  least  (Fig.  71). 

Fig.  71. 


The  lower  incisor  had  so  elongated  after  the  loss  of  the 
upper  lateral  that  it  almost  closed  upon  the  gum.  This 
was  partly  owing  to  the  abrasion  of  the  remaining  teeth, 
and  in  part  due  to  the  lower  incisor  gradually  rising  in 
the  alveolar  process.  Because  of  this  mal-occlusion  of  the 
teeth  a  porcelain  crown  (plain  "  plate-tooth")  with  "  cross- 
pins"  was  used,  and  fitted  and  soldered  to  the  gold  wire, 
there  being  no  space  for  a  backing  of  plate.  When  the 
wire  was  prepared,  the  porcelain  grooved  and  fitted  to  it, 
and  ready  for  the  placing-on  of  the  gold  foil,  the  whole 
crown  appeared  as  illustrated  (Fig.  70),  the  wire  extending 
into  each  root  about  four  lines,  or  full  three-eighths  of  an 
inch.     The  cutting-edge  of  the  porcelain  was  removed  to 


NOTES    ON    OPERATIVE    DENTISTRY.  147 

the  same  extent  that  the  incisors  were  abraded.  This  was 
done  in  order  that  the  gold  near  and  covering  the  labial 
edge  of  enamel  might  be  on  the  same  line,  and  that  the 
same  appearance  might  be  presented  and  the  same  pro- 
tection given  to  the  cutting-edge  of  each  tooth  (Fig.  71). 
The  wire  of  the  crown  was  held  in  a  hand-vise,  while 
cohesive  gold  foil  was  being  placed  and  made  compact  in 
the  grooves,  around  the  wire,  and  over  the  cutting-edge  of 
the  porcelain,  with  the  electro-magnetic  mallet.  The 
whole  contour  of  the  crown  was  thus  restored.  During 
the  final  fitting  of  the  crown,  its  base  was  accurately 
adjusted  to  the  gum,  and  so  prepared  as  to  rest  upon  it  in 
such  manner,  when  inserted,  as  to  press  the  blood  from 
the  capillaries  of  the  part.  When  ready  for  insertion, 
light-medium  rubber-dam  was  applied  to  the  two  teeth  on 
each  side  of  and  across  the  space  which  was  to  receive 
the  crown ;  small  barbs  were  made  all  around  the  wire 
with  a  sharp  knife,  and  oxychloride  of  zinc  was  placed  in 
the  pulp-chamber  of  the  central  incisor  and  cuspid,  and, 
while  the  cement  was  yet  in  a  plastic  condition,  the  crown 
was  pressed  to  place.  After  it  had  been  in  position  an 
hour  to  allow  of  complete  crystallization  of  the  oxy- 
chloride of  zinc,  portions  of  the  cement  and  of  the 
dentine  were  removed  with  a  small  bur,  so  as  to  obtain 
still  further  anchorage  for  the  gold  foil  then  put  in  place 
around  the  wire,  into  each  cavity,  and  over  the  prepared 
margins  of  enamel.  Principally  'No.  30  gold  (one-quarter 
ounce  cohesive  foil)  was  used  in  this  case,  and  each  piece 
was  solidly  compacted  with  the  electro-magnetic  mallet. 
A  few  pieces  of  light  folded  foil  were  placed  with  small 
hand-pressure  instruments  in  the  space  between  the  wire 
and  the  cervical  wall,  but  these  pieces  were  gone  over 
with  the  mallet  after  they  were  put  in  place.     With  this 


148 


NOTES    ON    OPERATIVE   DENTISTRY. 


and   all   the  operations  completed,  the  case  appeared  as 
illustrated  (Fig.  72). 

Under  favorable  circumstances,  as  many  as  eight  artifi- 
cial crowns,  in  place  of  the  incisors  and  bicuspids,  could 
be  permanently  attached  to  the  cuspids  and  first  molars ; 
but  that   the  operation   may   be   successful,  these  teeth 


Finished  case — a,  6,  d,  f,  g,  and  h,  pulpless  teeth  ;  g,  whole  crown  restored  with  gold  ;  o, /, 
and  h,  almost  entire  gold  crowns  ;  the  teeth  b  and  d  support  the  gold  crown  faced  with 
porcelain,  o,  and  fully  one-fourth  of  the  crown  of  each  of  these  is  restored  with  gold,  as  is 
also  that  of  e,  the  pulp  of  which  is  living. 

must  be  firm  in  their  sockets  and  very  little  recession  of 
the  gums  should  have  taken  place.  In  the  performance 
of  such  an  extensive  and  difficult  operation,  the  heavy 
gold  wire  (about  ISTo.  10,  18-carat)  to  which  to  attach  the 
crowns  should  be  well  fitted  and  anchored  in  the  pulp- 
chamber  of  each  cuspid.  The  wire  can  be  sufficiently  well 
anchored  in  the  molars  without  endangering  the  pulps. 
In  such  a  case,  as  in  all  others,  the  cavities  should  first  be 
prepared,  the  wire  then  fitted  and  the  crowns  attached, 
proper  occlusion  with  the  lower  teeth  secured,  the  parts 


NOTES    ON    OPERATIVE    DENTISTRY.  149 

built  out  with  foil,  and  the  whole  of  the  remaining  work 
entirely  finished  before  the  crowns  are  built  in  place. 
Each  crown  ought  to  be  as  separate  and  distinct  from  the 
other  (excepting  at  the  part  where  the  wire  is  fixed)  as 
the  crowns  of  the  natural  teeth — especially  the  base  of 
the  crown,  or  that  part  corresponding  with  the  neck  of  a 
tooth.  Thus  arranged  there  would  not  be  much  of  each 
crown  against  the  gum,  and  that  which  is  against  it 
should  be  nicely  fitted  and  be  close  enough  to  keep  out 
particles  of  food.  The  author  would  have  such  a  num- 
ber of  crowns  inserted  rather  than  wear  a  plate,  but  the 
whole  operation  would  have  to  be  well  performed,  by  a 
really  fine  operator,  or  it  should  not  be  done  at  all. 

Any  operator  of  ability,  who  will  endeavor  earnestly 
and  conscientiously  to  perform  the  various  operations 
herein  described,  can,  if  he  has  entire  charge  of  the  mouths 
of  his  patients,  secure  them  against  the  necessity  of  wear- 
ing plates  to  support  artificial  crowns,  excepting,  of  course, 
in  cases  where  the  teeth  are  lost  by  accident,  by  disease, 
such  as  extensive  necrosis  of  the  alveolar  border,  or  from 
the  natural  absorption  of  the  gums  and  alveolar  border 
late  in  life. 


IRRITATION  AND  DEATH  OF  THE  PULP. 


~rr  operations  are  not  performed  to  prevent  the  progress 
of  decay,  the  enamel  and  dentine  are  not  alone  liable 
to  be  remanded  back  to  primary  elements,  but,  through 
the  continuous  presence  of  agents  that  bring  about  solu- 
tion of  the  lime-salts,  especially  where  calcification  of  the 
tissue  is  imperfect  or  where  function  has  been '  interfered 
with,  the  pulp  is  soon  reached,  when  pain  or  disease  is 
incited  by  influences  operating  through  the  cayity  of 
decay. 

Irritation  of  the  pulp  may  be  brought  about  not  only 
by  the  agents  that  dissolve  the  lime-salts  from  the  basis- 
substance  of  the  hard  tissues — the  enamel  and  dentine — 
but  also  by  the  impingement  of  foreign  substances  or 
softened  dentine  upon  the  exposed  or  nearly-exposed 
tissue,  when  some  phase  of  odontalgia  or  neuralgia  may 
follow. 

If  irritation  of  the  pulp  be  due  to  the  acid  which 
brings  about  the  solution  of  the  lime-salts,  it  should  sub- 
side after  tepid  salt  water  has  been  injected  and  the  parts 
are  thus  cleansed,  the  softer  portions  of  dentine  removed, 
and  bicarbonate  of  soda,  potash,  or  ammonia  applied. 
Should  the  exposed  or  nearly-exposed  pulp  be  impinged 
upon  by  the  softened  dentine,  or  a  foreign  substance 
which  has  been  forced  during  mastication  upon  it,  and 
the  nutrient  currents  be  obstructed,  thus  inducing  irrita- 
tion, it  should  cease  after  the  removal  of  the  obstruction. 

150 


NOTES    ON    OPERATIVE    DENTISTRY, 


151 


When  the  pain  has  ceased,  the  parts  should 
be  dried  with  Japanese  bibulous  paper,  and 
an  application  of  carbolic  acid  should  be 
made  to  disinfect  the  dentine  which  may 
need  it,  and  to  coagulate  the  protoplasm 
at  the  exposed  part  of  the  pulp,  if  there  be 
such  exposure.  After  this  has  been  done  a 
piece  of  fine  card-board  should  be  placed 
over  the  nearly  or  fully-exposed  part  of  the 
pulp,  so  that  it  shall  not  be  pressed  upon 
during  the  insertion  of  gutta-percha;  all  of 
which  is  but  preparatory  treatment. 

After  the  pulp  has  been  thus  protected  and 
ease  secured  for  about  two  weeks,  the  rub- 
ber-dam should  be  applied,  the  temporary  fill- 
ing removed,  and  light  reflected  upon  the 
parts — this  should  be  done  during  the  per- 
formance of  every  operation — by  a  mouth- 
mirror  (Fig.  73),  when  all  the  decayed  den- 
tine should  be  cut  away,  except  the  part 
directly  over  the  pulp,  as  the  protection 
aflbrded  even  by  partially  decalcified  dentine 
is  much  better  than  an  artificial  covering, 
because  infiltration  of  lime-salts  is  very  likely 
to  take  place  throughout  the  basis-substance 
of  such  dentine.  When  this  has  been  done, 
and  the  warm-air  syringe  (Fig.  74)  has  been 
used  to  drive  out  the  moisture  as  Avell  as  to  ex- 
pel the  chippings  from  the  cavity,  the  dentine 
remaining  over  the  pulp  should  be  moistened 
with  carbolic  acid  or  a  saturated  solution  of 
salicylic  acid  in  alcohol.  To  place  a  capping 
or  to  put  artificial  protective  covering  over 


Fig.  73. 


152 


NOTES    ON    OPERATIVE    DENTISTRY. 


a  nearly  or  partly-exposed  pulp,  it  is  best  to  How  carbolic 
acid  over  the  part,  and,  before  evaporation  follows,  to  take 
some  of  the  oxide  of  zinc  on  the  end  of  a  small  spatula, 
place  it  at  the  entrance  to  the  cavity,  and,  'with  a  pufi  of 
warm  air,  spread  it  over  and  about  the  exposure,  there  to 
Fig.  74.  .  be  retained  by  the  deliquesced  car- 

bolic acid.  After  this  has  been  done, 
put  in  oxychloride  or  (preferably  in 
many  cases)  oxyphosphate  of  zinc, 
so  mixed  and  placed  as  to  flow  down 
one  side  of  the  cavity,  over  the  layer 
of  oxide  of  zinc  and  carbolic  acid, 
over  the  whole  of  the  dentine,  and 
to  the  outer  margin  of  enamel.  The 
rubber-dam  should  not  be  removed  for 
about  an  hour  after  the  cement  has 
been  placed  in  the  cavity,  because 
dryness  favors  its  perfect  crystal- 
lization. These  cases  should  be  kept 
in  this  condition  for  some  time  (in 
some  instances  a  year  or  more)  be- 
fore inserting  the  permanent  filling, 
although  under  favorable  conditions 
the  operation  may  be  proceeded  wdth 
immediately  or  very  soon  after  the 
oxychloride  of  zinc  has  hardened; 
but,  whenever  the  operation  is  to  be 
performed,  enough  of  the  cement 
should  be  retained  to  protect  the  pulp 
from  thermal  changes,  and  yet  sutficient  must  be  removed 
to  secure  proper  anchorage  for  the  gold. 

When  simple  shock  in  healthy  tissue  takes  place  on 
account  of  cold,  warmth  restores  the  nutrient  currents. 


NOTES    ON    OPERATIVE    DENTISTRY.  153 

For  instance,  if  a  large  cavity  is  filled  with  gold  without 
the  dentine  having  had  such  protection  from  thermal 
currents  as  oxychloride  of  zinc  affords,  cold  water  shocks 
the  tissue,  and  the  pain  which  follows  usually  ceases  upon 
the  application  of  warm  fluids.   . 

When  anything  irritates  the  pulp,  there  is  an  increase 
in  the  neural  and  vascular  currents  to  the  parts.  Cold 
drives  or  keeps  back  part  of  the  molecules  of  living  mat- 
ter and  the  blood-corpuscles,  and  ease  for  the  time  at 
least  is  secured.  Heat  induces  acceleration  of  the  currents, 
thus  favoring  the  swelling  of  the  granules  throughout  the 
protoplasmic  bodies  of  the  pulp,  and  those  at  the  point  of 
intersection  in  the  net-work  of  li^•ing  matter ;  the  blood 
(the  flow  of  which  is  increased  by  the  warmth)  in  the 
capillaries  so  presses  upon  the  fibers  of  living  matter  that 
the  pain  is  intensified,  until  the  vessels  are  ruptured,  and 
the  fibers  are  torn  at  the  end  of  the  root. 

Every  effort  ought  to  be  made  to  preserve  the  pulp  in 
each  case  presented,  and  particularly  where  the  enamel 
and  dentine  are  not  fully  calcified.  It  is  even  better  to 
retain  a  pulp  that  is  not  quite  in  the  normal  condition 
than  to  have  it  die  before  the  patient  arrives  at  the  age 
of  maturity,  because  a  possible  further  infiltration  of 
lime-salts  throughout  the  basis-substance  of  the  hard  tis- 
sues can  be  hoped  for.  .  Dr.  Bodecker  has  demonstrated 
that  the  myxomatous  condition  is  the  normal  physio- 
logical condition  of  the  pulp,  while  the  fibrous  condition 
is  the  result  of  morbid  action  and  inflammation  of  the 
pulp,  which  destroys  the  myxomatous  tissue  and  replaces 
it  with  fibrous. 

If  the  death  of  a  pulp  cannot  be  prevented,  the  tissue 
should  be  removed  from  its  chamber  as  soon  as  vitality  is 
lost  to  the  extent  that  its  removal  may  cause  but  little 


154  NOTES    ON    OPERATIVE    DENTISTRY. 

pain.  The  ether-spray  may  be  used  successfully  in  many 
cases,  the  cold  induced  through  the  rapid  evaporation 
of  the  ether  driving  or  keeping  back  the  neural  and  vas- 
cular currents  while  the  yet  partially  vital  tissue  is  being 
removed. 

If  arsenic  is  used  at  all  for  devitalizing  pulps,  it  ought 
to  be  very  carefully  applied  to  the  tissue,  and  only  in 
minute  quantity,  and  should  be  covered  with  a  piece  of 
courtplaster  of  suitable  size.  The  entire  cavity  should 
then  be  filled  with  gutta-percha  in  such  manner  that  it 
and  the  arsenic  cannot  be  displaced.  The  careless  and 
unreliable  method  of  placing  pellets  of  cotton  saturated 
with  sandarac  varnish  in  cavities  should  not  be  resorted 
to.  Even  with  the  greatest  care,  arsenic  is  a  dangerous 
substance  to  handle,  for  many  have  been  the  cases  of  ne- 
crosis traceable  directly  to  the  abuse  if  not  to  the  use  of 
this  material. 

In  some  few  cases  where  the  bulbous  portion  of  a  pulp 
has  become  devitalized  without  the  application  of  a  drug, 
and  has  sloughed  away  from  the  still  living  part  in  the 
root  or  roots,  the  living  portion  has  been  carefully  capped, 
and  has  remained  in  a  tolerable  condition,  at  least,  for 
such  length  of  time  as  to  indicate  the  performance  of  this 
operation  under  favorable  conditions  rather  than  the 
destruction  of  the  tissue  and  the  substitution  of  a  foreign 
material. 

When  pulp-tissue  has  been  carefully  removed  with 
small  broaclies  having  fine  barbs  upon  them  (Fig.  75)  before 
putrescence  occurs,  and  the  parts  have  been  cleansed,  the 
apical  foramen  should  be  closed  entirely  with  light  gold  foil, 
80  that  infiltration  cannot  take  place,  and  the  pulp-cham- 
ber and  cavity  of  decay  may  be  permanently  filled  at  once. 

Should  pulp-tissue  not  be  removed  soon  after  its  de- 


NOTES   ON   OPERATIVE   DENTISTRY. 


155 


Fig.  75. 


vitalization,  or  l)eforc  putrescence  takes  place,  sulphureted 
and  phosphureted  hydrogen-gas  from  the  disintegrating 
pulp  may  escape  through  the  apical  foramen  (particularly 
if  the  cavity  of  decay  be  closed),  and  irri- 
tation of  the  tissues  that  surround  or  are  \ 
adjacent  to  the  end  of  the  root  may  bo 
thus  induced.  This  irritation  may  be  in- 
cited not  only  by  the  gas,  but  also  by 
particles  of  the  pulp  or  any  foreign  matter 
which  may  be  forced  through  the  foramen 
during  the  cleansing  of  the  pulp-chamber. 

The  patient  should  be  informed  of  the 
symptoms  likely  to  be  manifested,  and  be 
advised  to  call  at  once  when  pain  is  indicated  or 
pronounced ;  and  if  there  be  such  symptoms  after 
the  putrescent  matter  has  been  carefully  removed, 
the  parts  disinfected  and  cleansed,  and  the  pulp- 
chamber  and  cavity  of  decay  temporarily  filled 
with  cotton  and  gutta-percha,  this  dressing  should 
be  removed,  a  short  time  given  for  the  escape  of 
the  gases  or  fluid  which  may  be  about  the  end 
of  the  root,  and  the  parts  again  closed.  Several 
such  dressings  may  be  required  before  normal 
action  has  been  re-established  within  the  perice- 
mentum, when  a  permanent  filling  of  gold,  or 
gold  to  close  the  foramen,  and  then  oxy chloride 
of  zinc,  should  be  inserted.  The  indications  of 
pericementitis  and  alveolar  abscess  are  about  the 
same,  with  the  exception  that  in  abscess  the  pain  is 
dull  and  is  confined  principally  to  the  end  of  the  root. 

When  gas  emanating  from  putrescing  and  disintegrat- 
ing pulp-tissue  escapes  through  the  apical  foramen,  nutri- 
tion of  the  elements  of  the  tissues  about  the  apex  of  the 


156  NOTES    ON    OPERATIVE    DENTISTRY, 

root  is  interfered  with.  A  separation  of  the  elements  of  a 
part  of  the  tissues  is  incited  by  this  gas,  which  is  absorbed 
by  the  watery  fluids  exuding  from  the  adjacent  capillaries, 
and  inception  of  alveolar  abscess  is  thus  pronounced.  If 
conditions  are  such  that  there  cannot  be  return  to  normal 
action, — ^if  there  is  an  accumulation  of  pus-corpuscles, — 
distention  of  the  parts  takes  place,  and,  because  of  the 
presence  of  the  pus-corpuscles,  severe  pain  is  induced,  and 
absorption  of  that  part  of  the  alveolar  process  ensues,  all 
of  which  continues  until  the  contents  of  the  sac  are  dis- 
charged, either  through  the  apical  foramen  or  the  alveolus. 
Dr.  Bodecker  has  seen,  under  the  microscope,  that  the 
"  sac  is  a  product  of  plastic  pericementitis, — it  is  built  up 
of  dense  fibrous  connective-tissue.  The  inner  surface  of 
the  sac  is  not  smooth,  but  largely  provided  with  irregular 
protrusions,  or  papillary  outgrowths  of  a  myxomatous 
structure,  crowded  with  inflammatory  elements." 

If  a  discharge  of  pus  does  not  follow  the  removal  of  a 
temporary  filling  or  dressing,  the  foramen  should  be 
slightly  enlarged  to  allow  of  the  escape  of  the  purulent 
liquid.  Even  should  abscess  follow,  and  though  the  pain 
before  the  pus  is  discharged  through  the  alveolar  process 
may  be  severe  (unless  the  patient  be  kept  during  this  time 
partially  under  the  influence  of  morphia),  yet  no  such 
manifestation  will  be  likely  to  ensue  when  normal  action 
of  the  parts  again  takes  place,  if  the  pulp-chamber  is  thor- 
oughly cleansed,  and  the  entire  chamber  and  cavity  of 
decay  properly  and  permanently  filled. 


FILLING  PULP-CHAMBERS. 


"TTTHERE  death  of  the  pulp  has  just  taken  place,  or 
^  ^  in  those  cases  where  the  tissue  has  not  become 
putrescent,  the  apical  foramen  should  he  closed  with  gold 
as  soon  as  the  bleeding  has  ceased, — exudation  of  blood 
usually  following  the  rupture  of  the  vessels  by  the  re- 
moval of  the  pulp  from  the  end  of  the  root.  The  parts  of 
the  vessels  that  are  ruptured  at  the  apical  foramen  while 
the  pulp  is  being  removed  retract ;  the  vessels  which  con- 
vey the  nutritive  supply  to  this  tissue  transport  it  to  other 
pulps  or  parts,  and  when  extravasated  blood  remains 
about  the  end  of  the  root  or  roots,  as  the  result  of  the 
rupture  of  the  capillaries,  it  is  absorbed  and  a  tolerable 
condition  again  established.  Some  obstruction  ^ig-  76. 
of  the  current  in  the  capillaries  within  the  peri- 
cementum is  sometimes  induced  through  the 
death  of  the  pulp ;  but  this  is  usually  evanes- 
cent, particularly  if  the  devitalized  tissue  is  at 
once  removed. 

By' opening  through  the  crown  of  a  molar  or 
other  tooth,  each  pulp-chamber  can  be  made 
accessible.  Gold  ought  to  be  used  for  closing 
the  foramen,  for  the  reason  that  narrow  strips 
of  light  foil  can  be  put  in  place  with  the  cer- 
tainty of  having  the  air  in  the  pulp-chamber 
pass  out  alongside  of  the  piece  of  foil  as  it  is  carefully 
moved  toward  the  end  of  the  root, — using  such  instru- 
ments as  are  here  illustrated  (Fig.  76). 

157 


158  NOTES    ON    OPERATIVE    DENTISTRY. 

The  accurate  measurement  of  the  length  and  diameter 
of  the  pulp-chamher,  which  should  always  be  taken 
just  before  introducing  the  gold,  can  be  more  strictly 
observed  in  closing  the  foramen  with  foil  than  in  the 
introduction  of  oxychloride  of  zinc  or  gutta-percha. 
When,  also,  foil  is  placed  as  near  to  the  end  of  the  root 
as  is  possible  without  passing  through  the  foramen,  the 
gold,  when  carefully  and  solidly  put  in  place,  entirely 
prevents  fluids  from  entering  the  pulp-chamber ;  and  this 
is  the  most  important  point  about,  and  almost  the  entire 
object  in,  filling  pulp-chambers.  If  the  foramen  be  not 
properly  closed,  the  filling  of  pulpless  teeth  cannot  well 
be  otherwise  than  unsatisfactory,  and  the  operation  an 
almost  useless  one.  Whenever  a  small  broach  can  be 
passed  to  the  end  of  a  root,  the  foramen  can  be  closed 
with  gold.  The  pulp-chamber  should  first  be  thoroughly 
cleansed,  and  the  foramen  then  closed  with  light  gold  foil 
folded  once  upon  itself,  or  made  into  three  or  four  thick- 
nesses, and  cut  into  very  narrow  strips.  Cotton  is  the 
next  best  material  for  the  filling  of  pulp-chambers.  The 
cotton  should  be  moistened  with  carbolic  acid,  a  few  fibei-s 
at  a  time,  and  then  carefully  placed  in  position  at  the 
foramen,  and  so  solidly  packed  as  to  prevent  infiltration 
of  fluids  from  the  end  of  the  root.  It  can  thus  be  carried 
to  the  foramen  easier  than  if  saturated  with  oxychlorjde  of 
zinc.  It  is  sometimes  necessary  to  take  a  fine  drill  (Fig.  77) 
Fig.  77.*  and  carefully  enlarge  the  pulp-chamber,  but  it 
'  .1  r  i  is  better  to  fill  to  the  end  of  the  root  without 
the  drilling.  After  the  dead  pulp  has  been  re- 
moved and  its  chamber  properly  prepared  for 
filling,  the  foramen  should  be  closed  with  gold, 
and  then,  and  not  till  then,  the  pulp-chamber  can  be  safely 

*  Gates's  drills. 


NOTES    ON    OPERATIVE    DENTISTRY.  lo9 

filled  with  oxychloride  of  zinc,  instead  of  i?old,  and  the 
operator  can  be  quite  certain  to  get  this  material  to  the 
gold  at  the  end  of  the  root,  and  get  the  air  out  at  the 
same  time.  The  foramen  being  closed  with  gold,  the 
oxychloride  of  zinc  cannot  pass  through  to  the  end  of 
the  root  any  more  than  liuids  can  thus  enter  the  pulp- 
chamber.  It  is  well  to  use  oxychloride  of  zinc  in  this 
manner  instead  of  gold,  in  some  cases  (as  in  those  where 
the  pulp  has  remained  dead  in  its  chamber  for  some  time, 
and  where  an  abscess  has  been  formed),  for  the  reason 
that  the  chloride  of  zinc  coagulates  the  protoplasm,  and 
prevents  or  arrests  the  decomposition  of  the  ends  of  the 
fibers  in  the  dentinal  canaliculi.  In  closing  the  foramen 
each  narrow  strip  of  foil  should  be  taken  on  the  end  of  a 
suitable  packing-instrument  and  placed  near  the  end  of 
the  root,  tapping  carefully  with  a  light  hand-mallet  till 
the  feel  and  the  sound  of  the  instrument  indicate  that  the 
gold  is  placed  solidly  in  position.  There  is  less  liability 
of  getting  gold  through  the  foramen  against  or  into  the 
tissues  outside  the  end  of  the  root  by  tapping  the  instru- 
ment with  a  mallet  than  by  placing  the  foil  in  position  by 
pressure. 


TREATMENT  OF  ABSCESS. 


TX  the  treatment  of  pulpless  teeth,  and  especially  those 
-^  wherein  the  pulp  has  been  dead  for  some  time  and 
abscess  is  in  its  incipiency,  or  where  it  has  gone  on  to 
such  an  extent  as  to  prevent  rebuilding  of  the  tissues 
surrounding  the  end  of  the  root,  it  is  sometimes  necessary 
to  carry  a  small  drill  just  through  the  foramen,  so  as  to 
make  a  fresh  wound,  and  secure  healing  by  "  first  inten- 
tion," without  inflammation  or  suppurative  action ;  for,  so 
long  as  putrescent  tissue  remains  in  the  pulp-chamber, 
and  the  mephitic  gas  arising  from  it  escapes  through  the 
apical  foramen,  so  long  may  the  production  of  pus-cor- 
puscles continue.  It  may  lead  to  the  almost  constant 
throwing  off  of  inflammatory  elements  or  pus-corpuscles 
from  the  tissue  that  is  involved.  This  transformation  of 
the  tissue  that  is  destroyed  into  pus  should  be  changed, 
and  the  parts  gotten  into  such  condition  as  to  favor  return 
to  normal  action,  else  the  abscess  may  become  chronic. 

Japanese  bibulous  paper,  carefully  wound  upon  a 
broach  of  suitable  size,  should  be  used  for  drying  out  the 
pulp-chamber  and  for  applying  remedial  agents.  If  the 
bibulous  paper  when  withdrawn  can  be  clearly  seen 
through  the  liquid  which  adheres  to  it,  when  examined 
with  a  magnifying  glass,  it  may  be  known  that  the  fluid  is 
protoplasm  from  the  elements  of  the  tissues  about  the  end 
of  the  root.  In  such  casas  a  little  deliquesced  chloride  of 
zinc  ought  to  be  carried  to,  but  not  beyond,  the  end  of 

160 


NOTES    ON    OPERATIVE    DENTISTRY.  161 

the  root,  to  coagulate  the  protoplasm,  when  the  foramen 
should  be  at  once  closed  with  gold,  and  the  entire  opera- 
tion may  then  be  completed.  If  the  surface  of  the  paper 
on  the  broach  cannot  be  so  clearly  seen  through  the  fluid 
after  withdrawing  it  from  the  pulp-chamber,  pus  may  be 
looked  for,  when  iurther  treatment  will  be  required. 
The  elements  of  the  tissues  about  the  end  of  the  root 
were  originally  uninterruptedly  connected  with  one  an- 
other as  the  elements  of  other  tissues  are,  by  delicate 
threads  of  living  matter,  and  thus  represent  what  is  called 
a  tissue.  "  If  the  inflammatory  elements  are  torn  apart, 
the  inflamed  tissue  ceases  to  be  a  tissue ;  it  is  destroyed — 
transformed  into  pus.  The  pus-corpuscles  are  the  inflam- 
matory elements  sprung  from  the  involved  tissue  itself." 

In  the  treatment  and  cure  of  abscess  where  there  has 
been  a  fistulous  opening,  it  is  often  necessary,  after  re- 
moving every  part  of  the  disintegrated  pulp-tissue,  to 
force  an  escharotic — carbolic  acid  or  creasote — through 
the  apical  foramen  and  into  the  sac,  to  prevent  the  trans- 
formation of  the  inflammatory  elements  into  pus,  and 
also  through  the  fistule  to  the  surface  of  the  gum, 
after  which  there  will  likely  be  rebuilding  and,  to  some 
extent,  a  new  formation  of  tissue ;  provided  there  is  no 
further  interference  with  or  obstruction  to  the  circulation 
in  the  capillaries  of  the  pericementum,  and  nutrition  be 
such  that  normal  function  can  take  place. 

It  is  sometimes  necessary  to  gradually  enlarge  this  fis- 
tulous opening  with  pellets  of  cotton,  and  to  cut  the  alve- 
olar process  with  a  bur  to  reach  the  end  of  the  root  and 
remove  the  saccule,  if  this  newly-formed  connective-tissue 
still  be  there,  and  a  part  of  the  end  of  the  root,  if  it  be 
necrosed; — afterwards  securing  healing  by  granulations, 
the  rebuilding  of  tlie  tissues  taking  place  from  the  root 

11 


162  NOTES    ON    OPERATIVE    DENTISTRY. 

outwardly, — and  the  opening  at  the  gum  should  not  be 
allowed  to  close  till  reformation  of  the  tissues  of  the  part 
is  complete. 

Chronic  abscess  interferes  with  the  supply  of  nutrient 
material  to  the  cementum  through  the  vessels  held  within 
the  connective-tissue  covering  it,  and  notably  lessens  the 
vitality  of  the  parts ;  and,  in  consequence  of  this  obstruc- 
tion to  the  circulation,  the  vitality  of  the  pericementum 
may  thus  be  destroyed.  Then,  and  not  till  then,  all  the 
tissues  of  the  tooth — pulp,  dentine,  enamel,  and  cementum 
— are  in  a  non-^^tal  condition.  These  tissues  alone  may  not 
only  become  devitalized,  but,  if  function  within  and  about 
those  adjacent  be  so  interfered  with  as  to  prevent  the  sup- 
ply of  protoplasm  to  them,  they  may  become  involved; 
the  surrounding  alveolar  process,  and  even  a  portion  of 
the  maxilla,  may  become  necrosed,  and  still  further  com- 
plications arise,  because  of  the  continuous  action  and  ad- 
vancing stages  of  alveolar  abscess. 

In  cases  where  the  foramen  is  so  large  that  it  cannot 
without  great  difficulty  be  closed  with  foil,  because  of  the 
drilling  through  or  absorption  of  the  end  of  the  root,  a 
gold  wire  should  be  fitted  accurately  into  it,  and  carefully 
put  in  position  and  held  there  with  oxychloride  of  zinc ; 
after  which  the  whole  pulp-chamber  should  be  filled  with 
the  cement.  After  closing  the  foramen  in  each  of  the 
roots  of  molars  and  filling  the  greater  part  or  the  whole 
of  the  canal  in  each  root  with  gold,  it  is  best  to  fill  the 
bulbous  portion  of  the  pulp-chamber  and  a  part  of  the 
cavity  of  decay  with  oxychloride  or  oxyphosphate  of  zinc. 
"When  this  material  has  hardened,  sufficient  anchorage 
ought  to  be  made,  and  the  operation  completed  with 
gold.  "When  it  is  necessary  to  use  the  pulp-chamber  for 
anchorage,  as  in  cases  where  the  greater  part  of  or  the 


NOTES    ON    OPERATIVE    DENTISTRY.  163 

entire  crown  is  to  be  restored  with  gold,  each  root,  as  well 
as  the  bulbous  portion  of  the  chamber,  should  be  filled 
entirely  with  cohesive  foil,  made  solid  throughout  by  the 
use  of  the  mallet.  In  most  cases  the  gold  in  the  pulp- 
chamber  can  thus  l)e  made  as  strong  as  wire,  and,  because 
of  the  more  perfect  adaptability  of  foil,  better  anchorage 
is  secured. 


PERICEMENTITIS. 


rinHERE  is  a  difference  between  alveolar  abscess  and 
pericementitis,  which  takes  place  about  the  neck  of 
a  tooth.  Alveolar  abscess  is  the  breaking-down  of  tissue 
into  pus  at  the  end  of  a  root,  while  pericementitis  about 
and  beyond  the  neck  of  a  tooth  is  a  suppurative  inflam- 
matory process,  and  necrosis  of  a  portion  of  the  surround- 
ing alveolar  border  may  follow,  as  in  what  is  called 
"  Riggs's  disease."  The  first  step  for  the  cure  of  alveolar 
abscess  is  to  get  rid  of  the  pus,  which  is  a  direct  product 
from  the  inflamed  part  or  tissue  involved  about  the  end 
of  the  root.  Pericementitis  usually  subsides  after  the 
thorough  removal  of  calcareous  deposits  from  the  neck  of 
the  tooth  with  instruments  called  scalers  (Fig.  78),  or  the 
cutting  or  burring  away  of  the  necrosed  portion,  if  there 
is  necrosis,  of  the  alveolar  border. 

There  are  two  varieties  of  pericementum, — ^the  myxoma- 
tous and  the  fibrous.  The  former  is  the  connective-tissue 
covering  the  cementum  of  the  teeth  of  young  persons, 
which  in  the  adult  changes  to  the  fibrous  variety. 

In  pericementitis  there  is  a  return  of  the  fibrous  con- 
nective-tissue to  the  myxomatous,  and  from  this  to  its 
embryonal  condition.  If  the  fibers  of  living  matter  con- 
necting the  connective-tissue  corpuscles,  forming  the  re- 
ticulum throughout  the  pericementum  and  joining  like 
fibers  from  the  adjacent  bone-corpuscles  of  the  alveolus, 
be  not  broken,  the  rebuilding  of  this  or  the  formation  of 
164 


NOTES    ON    OPERATIVE    DENTISTRY. 


165 


new  tissue  takes  place,  through  the  course  of  embryonal 
to  myxomatous,  and  thence  ^^'^-  '^^^ 

to    fibrous    connective-tissue  ^X 
again.     If   the   net-work   of 
living  matter  be  broken,  the 
part  torn  ceases  to  be  a  tis- 
sue, and  pus   is   the  result. 
After  the  healing  of  perice- 
mentitis  there  is   not   quite 
the  same  arrangement  of  the 
elements  as  at  first.     A  so-called  "  cicatricial  tis- 
sue "  is  formed,  in  which  there  is  a  closer  and 
more   irregular   distribution  of  connective-tissue 
bundles. 

Pericementitis  is  either  plastic  or  suppurative. 
In  the  first  a  new  tissue  is  formed ;  in  the  second 
the  fibers  of  living  matter  are  torn,  the  part  ceases 
to  be  a  tissue,  and  pus-corpuscles  form  from  the 
embryonal  mass.  The  fibers  of  the  living  matter 
of  the  pericementum  are  connected  directly  with 
those  from  the  protoplasmic  bodies  of  the  cemen- 
tum,  and  also  with  those  of  the  Haversian  canals 
and  those  in  the  canaliculi  of  the  bone,  so  that, 
wherever  destruction  of  the  pericementum  takes 
place,  necrosis  of  the  bone  is  the  result. 

In  the  extraction  and  replacement  of  teeth  for 
the  "  cure  "  of  abscess,  there  is  tearing  and  after- 
ward imperfect  connection  of  the  fibers  and  net- 
work of  living  matter.  If  the  minute  structure 
of  the  tissues  of  the  part  were  properly  under- 
stood and  appreciated,  no  practitioner  would  resort 
to  extraction,  but  would  bring  about  healing  while 
keeping  the   tooth  to  be  operated   upon   in   its 


166  XOTES    ON    OPERATIVE   DENTISTRY. 

place.  Inflammation  results  from  the  breaking-down  of 
the  pericementum  occasioned  by  the  tearing  of  the  tis- 
sue and  the  net-work  of  living  matter  when  extraction  is 
resorted  to. 

The  absorption  of  a  root  or  part  of  a  root  is  the  dissolv- 
ing away  of  the  lime-salts  in  the  basis-substance  of  the 
cementum,  causing  bay-like  excavations  which  are  filled 
with  protoplasmic  bodies  (myeloid  bodies — "  giant-cells  "). 
These  excavations  almost  always  result  from  pericemen- 
titis. The  rebuilding  of  cementum  and  the  formation  of 
the  fibrous  variety  of  pericementum  may  take  place, 
however,  especially  when  extraction  is  not  resorted  to 
and  the  fibers  of  living  matter  are  not  torn.  Extraction 
of  a  tooth  or  root  or  destruction  of  a  pulp  should  very 
rarely  be  resorted  to,  because  of  the  breaking  of  the 
fibers  and  tearing  of  the  net-work  of  living  matter,  even 
if  it  be  only  of  a  part :  for,  be  it  remembered  that  all  the 
tissues  throughout  the  body  are  uninterruptedly  con- 
nected by  very  fine  fibers  of  living  matter  in  the  form 
of  a  reticulum. 

The  results  of  Dr.  Bodecker's  researches  on  pericemen- 
tum and  pericementitis  are  summed  up  by  him  in  the 
following  points  : 

"  I.  Pericementum  is  a  layer  of  connective-tissue  be- 
tween the  root  of  the  tooth  and  the  wall  of  the  alveolus, 
and  common  to  both.  This  connective-tissue  in  the 
juvenile  condition  is  myxomatous,  rich  in  protoplasmic 
bodies.  In  the  adult  it  is  fibrous,  scantily  supplied  with 
protoplasmic  bodies,  the  so-called  connective-tissue  cells. 
The  bundles  of  the  connective-tissue  are  continuous  with 
those  of  the  gum,  and  with  those  of  the  periosteum  of 
the  alveolus. 

"  n.  Inflammation  of  the  pericementum   is   either   a 


NOTES    ON    OPERATIVE    DENTISTRY.  167 

plastic  (formative)  or  suppurative  (destructive)  process. 
These  two  kinds  dit!er  from  each  other  only  in  degree 
and  intensity. 

'•  m.  Plastic  pericementitis  is  characterized  by  the 
formation  of  nests  of  inflammatory  elements,  arising  from 
medullary  elements  which  have  appeared  from  the  con- 
nective-tissue after  dissolution  of  its  basis-substance. 

"  IV.  Plastic  pericementitis  may  terminate  in  resolu- 
tion, if  the  inflammatory  elements  be  not  numerous,  and 
the  basis-substance  be  re-established :  or  it  leads  to  hy- 
perplasia of  the  connective-tissue,  if  a  large  number  ot 
inflammatory  elements  have  formed  and  the  inflammatory 
process  has  repeatedly  recurred. 

"  V.  Pericementitis  in  its  more  intense  degrees  is  al- 
ways accompanied  by  cementitis  of  the  root  of  the  tooth, 
and  by  osteitis  of  the  wall  of  the  alveolus.  Plastic  peri- 
cementitis leads  to  a  new  formation  of  cementum  as  well 
as  of  bone-exostosis. 

"  VI.  Suppurative  pericementitis  results  from  the  break- 
ing apart  of  the  inflammatory  elements  which  have  arisen 
from  the  connective-tissue  of  the  pericementum  itself. 
Emigrated  colorless  blood-corpuscles  probably  share  in 
the  formation  of  pus-corpuscles  ;  but  no  proof  thereof  is 
possible.  The  main  mass  of  pus-corpuscles  is  due  to  a 
transformation  and  destruction  of  the  inflamed  tissue." 


NECROSIS. 


T"F  this  were  intended  to  be  a  complete  work  on  Oral 
-*-     Surgery,  it  would  Ije  necessary  to  give  in  detail  all 
that  relates  to  necrosis  of  the  maxillae,  including  various 
operations,  purely  surgical,  that  have  not  been  mentioned  , 
herein. 

IS^ecrosis  resulting  from  suppurative  pericementitis,  and 
the  death  of  the  alveolar  border  or  edge  of  bone  sur- 
rounding the  teeth  near  their  necks,  in  what  is  called 
Riggs's  disease,  has  already  been  referred  to ;  but,  in 
addition  to  this,  it  seems  best  to  give  some  of  the  princi- 
ples (based  upon  the  latest  and  best  discoveries  in  embry- 
olog}'  and  histology)  relating  to  the  diagnosis,  removal, 
and  treatment  of  larger  or  more  extensive  portions  of  the 
maxilLe  in  necrotic  condition.  Hence  it  is  that  the  follow- 
ing article  by  Dr.  W.  H.  Atkinson,  of  Xew  York,  is  here 
presented  : 

"  REPRODUCTION  OF  BONE,  WITH  SPECIAL  REFERENCE  TO  THE 
VARIABLE  PORTIONS  OF  THE  MAXILL.'E. 

"  Xecrosis  has  been  looked  upon  as  a  sudden  stroke  of 
death  to  a  given  territory  of  bone.  This  is  the  exact 
opposite  of  the  truth  in  every  case  that  has  fallen  under 
my  observation,  in  my  own  or  the  practice  of  others, 
hospital  or  private.  However  sudden  the  privation  of 
nerve-current  and  blood-current  may  be,  there  must  be  a 
period  of  solution  of  tlie  lime-salts  of  the  part  involved, 
to  constitute  either  caries  or  necrosis. 

168 


NOTES    ON    OPERATIVE    DENTISTRY.  169 

"  It  is  to  the  understanding  of  this  process  that  we  are 
indebted  for  correct  diagnosis  and  treatment.  And  just 
here  we  enter  upon  the  dispute  between  the  old  expectante 
and  the  modern  pragmatic  extirpatkc  methods.  The  old 
says,  '  Let  alone,  and  await  the  setting  up  of  the  line  of 
demarkation  before  attempting  to  operate.'  The  new  says, 
'  Extirpate  the  carious  or  necrosed  portion,  just  so  soon  as 
it  is  possible  to  determine  the  portion  deprived  of  the 
nerve- and  blood-circulation;'  thus  limiting  and  marvel- 
ously  lessening  the  extent  of  the  destruction  of  tissue. 
Just  how  far  the  solution  of  lime-salts  may  extend  and 
the  part  still  be  amenable  to  re-solidification,  is  not 
definitelv  settled :  but  that  vigorous  cuttins;  at  this  time, 
through  the  dead  and  dying  portion,  well  into  the  healthy 
adjoining  tissues,  is  to  be  considered  good  conservative 
treatment,  is  no  longer  in  doubt. 

"  To  comprehend  the  loss  of  tissues  involves  an  under- 
standing of  their  production,  nutrition,  and  maintenance, 
as  displayed  in  embryological  histology,  no  less  than  the 
alternations  of  generation  of  the  small  bodies  which  are  the 
elements,  the  changes  of  which  constitute  nutrition  in  the 
adult.  Function  is  so  deeply  laid  in  the  basis  of  molecular 
metamorphosis,  that  we  must  accept  dogmatic  assertion  of 
primary  postulates  from  which  to  proceed,  rather  than 
claim  to  be  able  to  demonstrate  the  mutations  of  com- 
bination and  separation  of  the  elements  producing  the 
perceptible  mass-changes  in  the  organs  of  the  body  in 
health  and  disease.  Hence  our  knowledge  is  but  compara- 
tive rather  than  absolute  in  the  discriminations  of  healthy 
or  diseased  manifestations,  so  varied  by  constitutional  and 
accidental  conditions  of  environment. 

"  A  sort  of  compromise  beween  nutritional  changes  in 
the  adult  and   tissual   metamorphoses  in  the  embryo  is 


170  NOTES    ON   OPERATIVE   DENTISTRY. 

present  in  all  reproductions  of  tissues,  continuity  of  wlaich 
has  been  broken  by  mechanical,  chemical,  or  dynamic 
interruption  of  function.  All  reproduction  of  tissue  (other 
than  that  of  nutritional  maintenance)  demands  a  utricle, 
or  pocket  to  contain  the  pabulum,  or  protoplasm,  from 
which  is  then  to  be  evolved  the  elements  of  the  new  tissue 
which  is  so  to  be  rebuilt  according  to  the  demands  of  the 
type  of  the  destroyed  portions  of  tissue.  This  holds  good 
preeminently  in  bones,  nerves,  tendons,  and  blood-vessels. 
I  have  not  yet  seen  muscles  reproduced  in  this  way. 

"  The  prevailing  methods  in  surgery  of  treating  caries 
and  necrosis  by  expectante  and  drainage  should  no  longer 
be  resorted  to.  The  portions  already  dead,  or  greatly 
debilitated,  should  be  thoroughly  removed  well  up  to  the 
healthy  territory, — securing  a  pocket  to  receive  the  pabu- 
lum out  of  which  to  attain  reproduction  by  what  has  been 
called  '  first  intention.' 

"  All  tissues  arise  from  protoplasm.  If  we  regard  proto- 
plasm as  the  first  example  of  tissue,  arising  out  of  pabu- 
lum,— which  is  a  reduced  magma  of  food-elements, — we 
shall  then  regard  it  as  the  one  tissue,  modifications  of  which 
are  presented  in  the  various  tissues  composing  the  human 
body. 

"  In  the  light  of  this  view  of  the  subject,  we  must  give 
the  following  classification  of  tissues  : — 

"  I.  Protoplasm. 

"  II.  Indifferent  or  embryonal  corpuscles. 

"  ni.  Connective-tissue  corpuscles,  nerve-tissue  corpus- 
cles, and  muscular-tissue  corpuscles. 

"  IV.  Limitary-tissue  corpuscles.  (This  is  usually  denom- 
inated epithelium,  and  is  characteristic  of  skin,  membranes, 
and  some  forms  of  morbid  growths). 

"  Limitary  tissue  covers  the  body  as  a  whole  and  lines  all 


NOTES  ON  OPERATIVE  DENTISTRY.         171 

tracts, — phono-respiratory,  alimentary,  genito-urinary,  op- 
tical, auditory,  and  sudoriparous. 

"  To  enter  into  the  question  of  the  possibilities  respecting 
reproduction  of  epithelium  from  protoplasm,  without  re-, 
sorting  to  the  so-called  '  skin-grafting '  method,  and  dis- 
cuss the  point  of  a  possibility  of  attaining  a  new  formation 
not  readily  detectable  as  veritable  '  scar-tissue,'  would 
lead  us  too  far  from  the  immediate  object  of  this  paper, 
viz.,  the  possibility  of  reproducing  the  variable  portions 
of  the  maxillae  where  the  teeth  are  kept  in  situ  but  de- 
prived of  the  alveolar  plates  constituting  their  sockets. 
The  tooth-bearing  parts  of  the  jaw-bones  are  the  portions 
of  these  structures  liable  pre-eminently  to  caries  and  necro- 
sis. 

"  Examples  of  well-formed  jaw-bones  without  teeth  in 
man  are  too  rare  to  aiford  comparisons  as  to  liability  to 
deteriorate,  as  set  against  the  list  with  teeth.  No  case  of 
necrosis  of  an  edentulous  human  jaw  has  come  under  my 
observation  in  history  or  in  practice. 

"  Molecular  metamorphosis  (the  commerce  of  tissues) 
constitutes  the  measure  of  production,  maintenance,  and 
destruction  of  tissues ;  and  hence  must  be  apprehended  to 
enable  us  to  institute  l)eneficent  diagnosis  and  treatment. 
Normal  nutritional  changes  do  not  attract  attention.  But 
when  disease  (as  aberrant  molecular  metamorphosis  is 
called)  invades  the  body,  the  abnormity  forces  recognition. 
Disease  is  one  in  origin,  and  one  in  mode.  Debility  is  its 
origin,  and  modifications  of  tissue  its  mode,  the  degrees 
of  which  constitute  its  various  manifestations. 

"  Mal-nutrition  is  always  asthenic,  and  induced  by  star- 
vation through  deficiency  of  food,  or  bad  food,  contagion, 
or  mis-applied  remedies.  The  important  point  is  to  be 
able  to  distinguish  between  the  cases  that  are  sure  to  result 


172  NOTES    ON    OPERATIVE    DENTISTRY. 

in  destruction  of  bone  territories  deprived  of  pabulum, 
when  left  alone,  and  those  in  which  resolution  may  be 
induced  before  the  periostitis  becomes  osteitis.  Bone- 
structure  is  so  low  in  nutritional  endowment  that  it  is 
dangerous  to  trust  to  any  constitutional  or  local  treatment 
other  than  prompt  extirpation  of  the  seat  of  inflamed 
bone,  from  which  caries  or  necrosis  is  sure  to  spread 
if  not  promptly  and  thoroughly  removed  quite  up  to  or 
slightly  beyond  the  limit  of  healthy  territory. 

"  To  comprehend  the  reproduction  of  any  tissue,  organ, 
or  system,  it  is  indispensable  to  be  acquainted  with  its 
production,  maintenance,  and  loss.  To  be  able  to  assert 
that  any  apprehensions  of  these  processes  are  new,  it  is 
also  indispensable  that  we  be  familiar  with  what  has  been 
known  or  assumed  by  those  who  have  dealt  .with  the  prop- 
ositions involved  in  the  subject. 

"  A  review  of  the  proceedings  of  those  engaged  in  treat- 
ing loss  of  bones  and  parts  of  bones  from  lesion  of  nutri- 
tion or  mechanical  lesion  will  fairly  indicate  the  status  of 
their  apprehension  and  comprehension  of  the  subject 
under  consideration.  The  range  and  variety  of  method 
and  management  is  sufficiently  extensive  to  satisfy  the 
most  strenuous  advocate  for  freedom, — all  the  way  from 
expectante  or  let-alone  treatment  to  '  boiling  oil,'  '  low- 
ered heat,'  '  cauterization ;'  and  intermediate  modes,  down 
to  the  demoniac  '  imprisonment  of  the  part  in  plaster 
bandages,'  and  other  means  of  absolute  '  fixity,'  may  be 
instanced  as  the  thorough-base  of  text-book  and  journal 
doctrine. 

"  He  who  takes  it  upon  himself  to  deal  with  the  disabili- 
ties and  sufferings  of  his  fellows,  in  morals,  medicine,  or 
surgery  proper,  should  ])e  so  divine  in  nature  as  to  be 
proof  against  being  dazed,  hardened,  or  deterred  from 


NOTES    ON    OPERATIVE    DENTISTRY.  173 

comprehending  each  case,  and  then  doing  with  steady 
purpose  whatever  is  indicated.  He  who  essays  to  help 
the  injured  should  be  so  in  love  with  nature  as  to  feel 
inclined  to  remove  every  obstruction  to  lier  methods,  in 
all  the  kingdoms  of  her  dominion,  be  it  in  mineral,  vege- 
table, animal,  or  human. 

"  What  naturalist  has  not  felt  impelled  to  release  the 
struggling  shoot  he  saw  wriggling  around  a  dry  leaf, 
stick,  or  stone,  to  attain  the  light  and  the  air  ?  In  like 
manner  the  truly  divine  surgeon  is  impelled  to  disregard 
mere  etiquette,  and  rush  to  the  help  of  the  afflicted  with 
kindly  inspirational  activity,  which  is  ever  auspicious 
wherever  the  afflatus  is  implicitly  followed. 

"  If  there  is  one  predominant  dead-weight  in  the  path  of 
the  surgeon  it  is  the  cold  assumption  to  know  exactly 
beforehand  all  the  ins  and  outs  of  a  complicated  operation, 
and  to  perform  it  '  secundum  artem.'  Timidity  and  rev- 
erent regard  for  text-book  authority  and  the  prevailing 
teachings  of  the  medical  schools  engender  hesitation  and 
doubt  as  to  the  correctness  of  the  deductions  aflTorded  by 
cases  in  practice. 

"  Little  by  little  advancement  was  made  as  the  light  of 
success  added  confidence  to  the  interpretations  arrived  at 
under  the  inspirations  of  necessity  in  cases  pronounced 
hopeless  by  those  in  authority.  When  several  of  these 
patients  recovered,  with  little  deformity,  some  of  those 
who  subsequently  saw  them  denied  that  they  had  ever 
been  veritable  cases  of  necrosis.  But  this  question  was 
easily  settled  by  the  testimony  of  competent  observers 
w^ho  saw  them,  and  by,  in  some  cases,  producing  the  bones 
themselves  that  had  been  removed  from  the  territory  now 
occupied  by  reproductions ;  which  reproductions  were  so 
exactly  normal  in  appearance  and  usefulness  of  function 


174  NOTES    ON    OPERATIVE    DENTISTRY. 

as  to  defy  detection  as  new  bone  by  any  who  had  not  seen 
them  in  the  course  of  death  of  parts,  removal,  and  the 
procurement  of  the  requisite  receptacle  or  pocket  in  which 
the  new  formations  were  obtained.  This  pocket,  by  the 
way,  is  the  sine  qua  non  to  success  in  these  undertakings. 

*'  The  heresy  of  the  vaunted  textual  statement  that '  peri- 
osteum is  the  bone-producer,'  has  now  happily  been  set 
at  rest  by  the  discovery  that  reproduction  of  tissues  follows 
the  same  course  of  metamorphosis  as  their  original  produc- 
tion. All  the  periosteum  that  is  yet  attached  to  the  soft 
tissues  surrounding  a  necrotic  territory,  and  which  has  the 
uninterrupted  supply  of  blood-vessels  and  nerves,  is  of 
great  importance,  and  should  be  sedulously  preserved. 
But  where  the  blood-  and  nerve-supply  are  cut  off,  the 
dead  periosteum  should  be  removed  with  the  necrosed 
bone,  since  it  is  no  longer  able  to  perform  its  functions. 

"  The  principal  use  of  the  connective-tissue  (constituting 
periosteum)  is  as  a  support  to  nerves  and  blood-vessels,  by 
which  pabulum  may  be  carried  to  its  inner  side,  next  to 
the  bone,  there  to  be  converted  into,  1st,  'protoplasm;' 
2d,  'embryonal  corpuscles;'  3d,  'bone-plates  of  osteo- 
blasts;' which,  4th,  become  true  bone  by  deposits  of  the 
recjuisite  lime-salts  ;  and,  lastly,  the  periosteum  then  serves 
as  means  of  sheathing  to  bone  and  tendqn  at  the  places  of 
attachment  or  insertion  of  the  muscle.  The  ado  made  by 
surgeons  for  the  necessity  of  preserving  periosteum  where 
reproduction  of  bone  is  desired,  will  be  superseded  upon 
a  close  study  of  embryological  bone-production. 

"  Written  or  spoken  directions,  however  clear  they  may 
be,  are  less  instructive  than  clinical  display  of  diagnosis 
and  treatment  of  cases  of  any  sort ;  but  especially  of  the 
simpler  ones  of  necrosis  and  caries.  Clinical  instructions, 
of  necessity,  are  limited  to  the  few  who  can  come  near 


NOTES    ON    OPERATIVE    DENTISTRY.  175 

enough  to  clearly  take  in  the  essential  features  of  the  ex- 
amination, deliberation,  and  discernment  of  the  diagnosis 
upon  which  the  treatment  depends. 

"  A  rigid  adherence  to  rules  in  diagnosis  frequently  j;ends 
to  render  a  true  one  impossible,  as  it  often  occurs  that  a 
step  in  the  operation  must  be  taken  before  diagnosis  can 
be  completed.  Furthermore,  early  symptoms  are  too  ob- 
scure to  be  detected  l)y  any  but  the  well-trained  observer. 
Just  so  soon  as  the  ability  to  detect  to  a  certainty  the 
departures  from  health  that  are  liable  to  run  into  caries 
and  necrosis  becomes  more  general  among  practitioners, 
there  will  no  longer  be  such  predominant  multiplicity  of 
examples  of  this  justly  detested  disease  I" 


.'V-'-'m-l^lS^V^ 


